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J Oral Maxillofac Surg61:728-730, 2003

Interesting Eruption of 4 TeethAssociated With a Large Dentigerous Cyst

in Mandible by Only MarsupializationUmit Ertas, PhD, DDS,* and M. Selim Yavuz, DDS

The dentigerous cyst has always associated with animpacted, embedded, or unerupted tooth.1-6 Most pa-

tients with a dentigerous cyst are younger than 20

years.2

The risk of cyst formation around the crowns of

unerupted mandibularfirst premolars, maxillary inci-sors, or mandibular second molars is significant.7 If

enlargement of the jaw occurs, it is progressive and

generally painless. It may cause displacement of adja-

cent teeth and resorption of teeth roots. Marsupializa-tion may be advisable to allow eruption of a cyst-

associated impacted or unerupted tooth, if sufficient

space exists.5

Two principal methods of treating a dentigerouscyst are removal and marsupialization. Excision is

indicated when there is no likelihood of damaging

anatomic structures such as apices of vital teeth, max-

illary sinus, or the inferior alveolar nerve. Marsupial-ization can maintain the impacted tooth in its cavity

and promote its eruption.8 Marsupialization is espe-

cially useful for dentigerous cyst with teeth displace-ment.

This report describes the case of a 9-year-old girl

with a large dentigerous cyst associated with mandib-

ular lateral incisor, canine, and first and second pre-

molar teeth. The cyst was marsupialized with thepatient under general anesthesia, and the patient waschecked biweekly. The impacted teeth erupted with-out orthodontic traction and therapy.

Report of a Case

A 9-year-old girl was referred to the oral and maxillofacialsurgery clinic of Ataturk University Faculty of Dentistry withthe complaint of mild swelling overlying the left side of themandible.

Extraoral examination revealed hard bony expansionoverlying the mandible. The oral soft tissues were within

normal limits, and inferior alveolar nerve function was in-tact.

Radiographic examination showed a large expansile radi-olucent region from the mandibular left second molar toothto the mandibular right canine tooth germ. The mandibularleft lateral incisor, canine, and first and second premolarteeth 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: [email protected]

2003 American Association of Oral and Maxillofacial Surgeons

0278-2391/03/6106-0018$30.00/0

doi:10.1053/joms.2003.50145FIGURE 1. Panoramic radiograph showing the large dentigerouscyst and displaced teeth.

728 ERUPTION OF 4 TEETH ASSOCIATED WITH DENTIGEROUS CYST


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The mandibular deciduous lateral incisor had been ex-tracted because of infection 2 years earlier. The response ofall teeth to electric pulp test was within normal limits. A

needle aspiration biopsy was performed on the initial visitto establish whether the lesion was solid or cystic. Findingsof that examination suggested that the lesion was a denti-gerous cyst. Because natural eruption of these teeth waspossible, it was decided to perform marsupialization. Undergeneral anesthesia, the mandibular left deciduous canineand molar teeth were extracted. After a buccal mucoperi-osteal flap had been elevated, the cyst membrane was fe-nestrated. A specimen was sent for microscopic examina-tion. Histopathologic examination revealed a diagnosis ofdentigerous cyst (Fig 2). The cyst membrane was sutured tooral mucosa to create a window. Then, a gauze iodoformpack was inserted into the cyst cavity to keep it open. Thepacking was replaced biweekly. The patient was examinedradiographically bimonthly. It was observed on the radio-

graph that the impacted teeth slowly moved toward thealveolar crest without orthodontic traction. After 2 months,the teeth were erupting slowly (Fig 3). After 6 months, theteeth reached half-way to the desired position (Fig 4). After11 months, the teeth reached the alveolar mucosa (Fig 5),and after 16 months, all teeth had erupted without orth-odontic traction (Fig 6).

We have followed the patient for 30 months (Fig 7);during this period, there has been no recurrence of the cyst.

Discussion

Dentigerous cysts are always associated with anembedded or unerupted tooth.1-5,9,10 Benn and Altini7

reported that 2 types of dentigerous cysts occur. The

first is developmental in origin and occurs in matureteeth usually as a result of impaction. These cystsusually occur in the late second and third decades, arediscovered on routine radiography, and predomi-nantly involve mandibular third molars.7

The second type is inflammatory in origin and oc-curs in immature teeth as a result of inflammationfrom a nonvital deciduous tooth follicle. These arediagnosed in the first and early part of the second

decade either on routine radiographic examination orwhen the patient complains of swelling and pain.9Webelieve that our case might be classified as the secondtype of dentigerous cyst. Because of age and clinicalbehavior, there is a relationship between our case andthe second type of dentigerous cyst. Furthermore, in

FIGURE 2. Histopathologic view of the lesion (hematocylin and eosinstain, original magnification 200).

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

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

FIGURE 5.Eleven months after marsupialization, teeth reached thealveolar mucosa.

ERTAS AND YAVUZ 729


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the medical history of the patient, it was noted thatthe deciduous lateral incisor tooth was extracted 2

years earlier. This clinical feature is typical for thesecond type of dentigerous cyst.

Treatment of dentigerous cysts is often enucle-ation. However, cysts causing tooth displacement andinvolving loss of bone should be treated with marsu-

pialization or decompression.2,11 In this method, newbone formation is stimulated because marsupializa-tion decreases intracystic pressure.2,12 The major dis-advantage of marsupialization is that pathologic tissueis left in situ, without a thorough histologic examina-tion.2,12Although the tissue taken in the window canbe submitted for pathologic examination, there is apossibility of a more aggressive lesion in the residualtissue.12

It is known that although a dentigerous cyst inhibitseruption of the cyst-associated permanent tooth, mat-uration of tooth roots continues.4

Miyawaki et al5 reported that an impacted tooth isable to erupt more rapidly if marsupialization is per-formed at a time when the tooth has the ability toerupt. There is a close correlation between eruptionand the development of teeth roots.2,5 Speed of erup-tion and rate of angulation of the cyst-involved per-

manent teeth were faster than those of the teeth onthe noncyst side.5

Takagi and Koyama2 reported that marsupializationis useful for promoting eruption of teeth associated

with dentigerous cysts.Orthodontic traction of impacted teeth with ma-

tured root has often been performed after marsupial-ization of a large cyst.4,10 However, in our case, allteeth erupted with only marsupialization without

orthodontic traction.The major disadvantage of marsupialization is that

pathlogic tissue is left in situ, without thorough his-tologic examination.2,12 Although the tissue taken in

the window can be submitted for pathologic exami-

nation, there is the possibility of a more aggressivelesion in the residual tissue.12 Although marsupializa-tion has these disadvantages, we treated our case withonly marsupialization because the patient was very

young, the cyst was very large, the cyst had led to thedisplacement of 4 permanent teeth, and mandibulardevelopment had not been completed.

We believe that the eruption of teeth is dependenton early age of the patient and incomplete root for-mation.

References1. Kaya O, Bocutoglu O: A misdiagnosed giant dentigerous cyst

involving the maxillary antrum and affecting the orbit. Casereport. Aust Dent J 39:165, 1994

2. Takagi S, Koyama S: Guided eruption of an impacted secondpremolar associated with a dentigerous cyst in the maxillarysinus of a 6-year-old child. J Oral Maxillofac Surg 56:237, 1999

3. Graydon S: Two dentigerous cysts in the mandible of onepatient: Case report. Aust Dent J 41:291, 1996

4. Golden AL, Foote J, Lally E, et al: Dentigerous cyst of themaxillary sinus causing elevation of the orbital floor. Oral Surg52:133, 1981

5. Miyawaki S, Hyomoto M, Tsubauchi J, et al: Eruption speed andrate of angulation change of a cyst-associated mandibular sec-ond premolar after marsupialization of a dentigerous cyst. Am JOrthod Dentofac Orthop 116:578, 1999

6. Lustig JP, Schwartz-Arad D, Shopina A: Odontogenic cysts re-

lated to pulpatomized deciduous molars clinical features andtreatment outcome. Oral Surg Oral Pathol 87:499, 1999

7. Benn A, Altini M: Dentigerous cysts of inflammatory origin: Aclinicopathologic study. Oral Surg Oral Pathol 81:203, 1996

8. Moro Antonio JM, Puente M: Surgical-orthodontic treatment ofan impacted canine with a dentigerous cyst. J Clin Orthod35:491, 2001

9. Mintz S, Alard M, Nour R: Extraoral removal of mandibularodontogenic dentigerous cysts: A report of 2 cases. J OralMaxillofac 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. JEndod 17:517, 1991

12. Peterson LJ, Ellis E III, Hupp JR, et al: Contemporary Oral andMaxillofacial Surgery (ed 3). St Louis, MO, Mosby, 1998, p 540

FIGURE 7. Thirty months after marsupialization, there has been norecurrence of the dentigerous cyst.

FIGURE 6. Sixteen months after marsupialization, teeth completelyerupted.

730 ERUPTION OF 4 TEETH ASSOCIATED WITH DENTIGEROUS CYST

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