Oral and Maxillofacial Surgery Cases: Ahmed Adel Salama, Adel Abou-Elfetouh
Oral and Maxillofacial Surgery Cases: Ahmed Adel Salama, Adel Abou-Elfetouh
Oral and Maxillofacial Surgery Cases: Ahmed Adel Salama, Adel Abou-Elfetouh
A R T I C L E I N F O A B S T R A C T
Keywords: The Dentigerous Cysts (DCs) are considered the most common developmental Odontogenic cysts
Dentigerous cyst (OCs), they are related to the crown of unerupted impacted tooth. These cysts are usually
Marsupialization asymptomatic; however, some cases complain of facial asymmetry, teeth displacement, root
Pediatric dentistry
resorption of adjacent teeth, and pain if inflammation occurs. Radiographic examination usually
Unerupted tooth
reveals a unilocular radiolucency with sclerotic borders and surrounding the crown of an uner
upted tooth. Classically, DCs are treated with enucleation and extraction of the involved tooth.
However, owing to the high prevalence of these cysts in children, marsupialization is followed as
a line of treatment that permits the eruption of the permanent tooth involved. This article pre
sents a case of left mandibular DC in a 7.5 years boy. Marsupialization was the treatment modality
chosen with a precisely fitted functional and removable acrylic obturator provided, where a 12-
months follow-up revealed complete uneventful healing of the lesion alongside eruption of the
involved tooth.
1. Introduction
Odontogenic cysts (OCs) comprise up to 90% of jaw cysts [1]. These can be defined as pathological cavities that are lined by an
epithelium originating from the process of odontogenesis and filled with fluid or semifluid content [2].
The classification of OCs has been widely debatable [3]. However, according to the World Health Organization (WHO), they can be
simply classified as inflammatory or developmental [1], where the radicular cysts represent the most prevalent inflammatory OCs
while the Dentigerous Cysts (DCs) are considered the most common developmental OCs [3].
The most commonly presenting type of DCs is related to the crown of an unerupted, impacted tooth and attaches it to the
cementoenamel junction. The other type, called eruption cyst, overlies an erupting tooth. Both are mostly found overlying first per
manent molars or deciduous incisors [3].
DCs are usually small and discovered during routine radiographic examination of the jaw. These cysts, in most cases, are
asymptomatic, however if infected, pain is elicited. DCs rarely assume large sizes displacing the associated impacted teeth and causing
marked expansion of the cortices of the jaw with an “eggshell-crackling” or “frog-belly” phenomenon upon palpation. Moreover, root
resorption of adjacent teeth does exist, albeit neurosensory deficits are uncommon [2].
Classically, DCs are treated with enucleation and extraction of the involved tooth [3]. Nevertheless, owing to the high prevalence of
these cysts in children, marsupialization is better followed as a line of treatment that permits the eruption of the permanent tooth
* Corresponding author. Pediatric Dentistry Department, Faculty of Dentistry, Cairo University, 11 El Saraya Street, Al Manial, Cairo, Egypt.
E-mail addresses: Ahmed.salama@dentistry.cu.edu.eg (A.A. Salama), a.abouelfetouh@dentistry.cu.edu.eg (A. Abou-ElFetouh).
https://doi.org/10.1016/j.omsc.2020.100200
Received 6 August 2020; Accepted 2 November 2020
Available online 5 November 2020
2214-5419/© 2020 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
A.A. Salama and A. Abou-ElFetouh Oral and Maxillofacial Surgery Cases 6 (2020) 100200
Fig. 1. Pre-operative panoramic radiograph showing a radiolucent unilocular lesion with sclerotic margins associated with an unerupted 1st left
mandibular premolar.
Fig. 2. CBCT revealing a cyst involving an unerupted tooth located in the lower left mandibular region.
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A.A. Salama and A. Abou-ElFetouh Oral and Maxillofacial Surgery Cases 6 (2020) 100200
involved, where children possess a great regenerative potential allowing tooth with incomplete root development to maintain the
eruptive strength [4].
The aim of this article is to present a case of dentigerous cyst in a child presenting with a swelling related to the lower left quadrant
and its surgical treatment, as well as the placement and evaluation of the role of a functional acrylic obturator.
2. Case description
A 7.5-year-old boy was referred to the Pediatric Dentistry Department, Faculty of Dentistry, Cairo University, complaining of severe
pain related to teeth 74 and 75. Clinically intraoral examination revealed a compressible swelling of the buccal cortical plates of the
alveolar ridge related to the lower left quadrant. Dentition was mixed with other carious teeth 54, 55, 56, 84, 85.
The radiographic findings, panoramic radiograph (Fig. 1) and cone beam computerized tomography (CBCT) (Fig. 2), revealed a
well-defined radiolucent lesion, with sclerotic margins, completely associated with the crown of the unerupted mandibular left first
permanent premolar. The root of the adjacent lower first and second primary molars were also involved in the lesion, with the presence
of root resorption. There was no sensorineural or motor deficit at the facial structures. Following the clinical and radiographic ex
amination, a provisional diagnosis of the dentigerous cyst was made.
Written informed consent was obtained from the child’s parents for all imaging exams, for the planned treatment modality, and for
the publication of the data presented in this paper.
Considering the age of the patient and vicinity to the lower border of mandible, marsupialization of the cystic cavity was planned to
preserve the unerupted tooth. Surgical intervention was carried out under general anesthesia in the Oral and Maxillofacial Department,
Faculty of Dentistry, Cairo University. The primary mandibular left first and second molars were extracted before the exposure of the
cyst cavity by opening a flap. After the flap opening process, the cyst cavity was identified (Fig. 3), and the contents of the cyst were
removed and sent for histopathologic evaluation where the diagnosis of dentigerous cyst was confirmed. The surgical procedure was
completed with no complications and analgesics were prescribed when needed.
Alginate impression was prepared less thick, so that its placement was soft. The fingerprint was taken with standard bucket filled
with alginate. The cystic cavity was filled with iodoform gauze that was changed after seven days following washing and disinfecting
the wound. On the seventh day a functional removable acrylic obturator (Fig. 4), that has been previously adjusted to the cystic
window, was delivered to the patient (Fig. 5).
The patient and his parents were informed about how to clean the lumen of the cyst using Betadine mouthwash twice per day. The
patient was recalled for follow-up and stent adjustment at the 4th, 8th and 12th weeks then every 3 months till complete healing of the
lesion and eruption of the successors. All the follow-up visits were uneventful with no complications.
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A.A. Salama and A. Abou-ElFetouh Oral and Maxillofacial Surgery Cases 6 (2020) 100200
Fig. 6. 12-months post-operative panoramic radiograph showing complete healing of the cyst with eruption of the left 1st mandibular premolar.
Fig. 7. 12-months clinical follow-up showing the eruption of the left 1st mandibular premolar.
3. Discussion
Asymptomatic lesions, discovered accidently in radiographs done for other reasons, are how DCs commonly present. However,
some cases might complain of facial asymmetry, teeth displacement, severe root resorption of adjacent teeth and even pain if
inflammation occurs [2].
Radiographic examination usually reveals a well-demarcated unilocular radiolucency with sclerotic borders and surrounding the
crown of an unerupted tooth, that was the mandibular left first permanent premolar in the presented case. Yet, depending on
radiographic films alone for diagnosis is not recommended, as the panoramic radiograph offers a ghost image that doesn’t support the
three-dimensional structure of the lesion, moreover, it offers variable degrees of distortion and amplification [5]. Accordingly, it was
mandatory to perform CBCT imaging for our patient to further evaluate the extent of the lesion.
CBCT imaging, as an advanced modality in evaluating cysts and benign tumors, has the advantage of recording all the three di
mensions of the lesion by the multiplanar (coronal, axial and sagittal planes) imaging technique that eliminate the superimposition of
anatomical structures [6].
Different factors dictate the choice of management of DCs. The involvement of supernumerary tooth might require enucleation of
the cyst along with extraction of the tooth [5]. On the other hand, marsupialization as a conservative treatment option would be
desirable if preservation of the involved tooth is the goal [4].
Indeed, Management of the DC in the presented case, 7.5 years-old boy with primary and mixed dentition, needed a special
consideration for the preservation of development of permanent teeth. Accordingly, marsupialization was the treatment of choice.
Marsupialization comprises suturing the cyst lining to the oral mucosa and conversion of the cyst into a pouch. Fewer complications
have been reported to this line of treatment compared to enucleation, probably owing to the preservation of important anatomical
structures and allowing the development of the permanent tooth germs [7].
In this report, the surgical procedure was completed with no complications and a week later a functional removable acrylic
obturator, penetrating inside the cystic pouch in order to decompress the lesion, was prepared and delivered to the patient. Indeed,
keeping the cyst opening patent and connected to the oral cavity via a removable device or gauze packing, has been documented in
various case reports [4,8].
In the present case, iodine gauze was placed in the bone defect only for one week. The prolonged application of iodine gauze is not
preferable as it is inconvenient to the patient; besides causing bad breath, the replacement of the gauze after surgery slows epithe
lialization of the defect owing to the removal of the surface layers of blood clot causing secondary bleeding [9].
A functional removable acrylic obturator was applied in our case for the reported advantages this technique offers. The obturator
acts as a space maintainer, restores the normal function of mastication, prevents contamination of the lesion or food accumulation in
the cystic pouch, its smooth surface prevents the removal of the formed blood clot, moreover, it hinders the formation of fibrous scar
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A.A. Salama and A. Abou-ElFetouh Oral and Maxillofacial Surgery Cases 6 (2020) 100200
which might impair the eruption of the permanent tooth [4]. The patient and his parents were instructed to irrigate the cystic cavity
with Betadine mouthwash after each meal to keep the cystic pouch clean as well as regularly cleaning the obturator.
The patient was summoned at 4, 8 and 12 weeks then every 3 months afterwards for follow-up. Clinically the patient was examined
for the condition and lining of the cystic cavity and adjusting the fitting of the acrylic obturator. Radiographic follow-up was performed
at 3, 6 and 12 months post-operatively.
It is worth mentioning that the use of marsupialization technique for treating DCs, associated with developing buds in a child,
necessitates a period of follow-up until the permanent tooth erupts [4] and to guard against recurrence or the possible development of
ameloblastic changes of the remnants of cyst lining [10].
As seen in Figs. 6 and 7, during follow-up of our case, a progressive improvement was observed both clinically and radiographically
where, after 12-months follow-up, the size of the lesion decreased along with obliteration of the cavity, and eruption of the involved
tooth.
Marsupialization, the chosen treatment modality, offers various advantages regarding the present case as well as similar cases; it
minimizes the risk of damage to nearby anatomical structures such as the inferior alveolar nerve and maxillary sinus, reduces the
cavity size, minimizes the damage to the involved bone tissue stimulating osteogenesis [11]; and finally promotes the eruption of the
involved teeth [4].
On the other hand, disadvantages exist for this technique, such as the demand for good patient cooperation, as well as the need for a
long period of follow-up till the eruption of the involved tooth, which might not be feasible for many patients, and these might be the
cause of failure of marsupialization as a treatment modality for DCs.
4. Conclusions
• Marsupialization and decompression techniques proved successful throughout the 12-months follow-up of the present case.
• The use of a precisely fitted functional and removable acrylic obturator, that was finely adjusted according to the size of the lesion
at each follow-up appointment, was a cornerstone in the success of the treatment.
• Long-term follow-up, that is mandatory to ensure full eruption of the involved tooth and rule out recurrence, along with the pa
tient’s cooperation in following the given instructions, played a major role in the success of this treatment modality.
Acknowledgement
The authors would like to express their deepest gratitude to dr. Yasmin M. Aboul-Ela, Lecturer, Clinical Pharmacology Department,
Faculty of Medicine, Ain Shams University, for assisting in the manuscript writing and providing language revision.
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