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Marsupialization: A conservative approach for treating dentigerous cyst in children in the mixed

dentition

BC Kirtaniya1, V achdev!, A ingla", AK harma#

1 $rofessor, %epartment of $edodontics, &imachal %ental College under 'agar, &imachal

$radesh, (ndia

! $rincipal, $rofessor and &ead, %epartment of $edodontics, &imachal %ental College under

'agar, &imachal $radesh, (ndia

" $rofessor and &ead, %epartment of )rthodontics, &imachal %ental College under 'agar,

&imachal $radesh, (ndia

# $ost *raduate tudent, %epartment of $edodontics, &imachal %ental College under 'agar,

&imachal $radesh, (ndia

%ate of +e $ulication 11-%ec !.1.

Astract

%entigerous cysts are usually encountered in the practice of pediatric dentistry/ 0he treatment

modalities range from marsupialization to enucleation of the lesion and are ased on the

involvement of the lesion ith the ad2acent structures/ &oever, loss of a permanent tooth in the

management of a dentigerous cyst can e devastating to a child ho has already a congenitally

missing tooth/ 0he first case descries the techni3ue of marsupialization in hich e extracted

the grossly carious deciduous 1st molar and created a indo through the extracted soc4et to

decompress the lesion/ (n this case the !nd premolars ere congenitally missing on oth sides of

the mandile for hich e had not gone for enucleation of the dentigerous cyst along ith the

developing 1st premolar/ 0he second case is a developmental type of a ig dentigerous cyst

here marsupialization as folloed y enucleation of the cystic lining ut ithout removal ofthe affected tooth/ Both the teeth erupted in the oral cavity/

Keywords: %entigerous cyst, enucleation, marsupialization, mixed dentition

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How to cite this article:

Kirtaniya B C, achdev V, ingla A, harma A K/ Marsupialization: A conservative approach for

treating dentigerous cyst in children in the mixed dentition/ 5 (ndian oc $edod $rev %ent

!.1.6!7:!."-7

How to cite this URL:

Kirtaniya B C, achdev V, ingla A, harma A K/ Marsupialization: A conservative approach for

treating dentigerous cyst in children in the mixed dentition/ 5 (ndian oc $edod $rev %ent 8serial

online9 !.1. 8cited !.1 )ct !96!7:!."-7/ Availale from: http:;;/2isppd/com;text/asp<

!.1.;!7;";!.";="=>

(ntroduction

%entigerous cysts are the most common of all developmental odontogenic cysts of the 2as and

account for approximately !.-!#? of the 2a cysts/ 0hey develop around the cron of an

unerupted tooth y expansion of the follicle hen fluid collects or a space is created eteen the

reduced enamel epithelium and the enamel of an impacted tooth/ 819 0hese cysts are alays

associated ith an unerupted tooth or a developing tooth ud and are found most fre3uently

around the cron of the mandiular "rd molars folloed, in order of fre3uency, y the maxillary

canines, maxillary "rd molars and, rarely, the maxillary central incisors/ 8!9 0he cyst may cause

selling, teeth displacement, tooth moility and sensitivity if it reaches a size larger than ! cm in

diameter/ 8"9 (n the radiograph, the dentigerous cysts usually sho a ell-defined unilocular

radiolucency, often ith a sclerotic order, surrounding the cron of an unerupted tooth/ 8!9

&istologically, the dentigerous cyst consists of a firous all lined y non-4eratinized stratified

s3uamous epithelium of myxoid tissue, odontogenic remnants and, rarely, seaceous cells/ 8#9 (f

untreated, these cysts may cause pathologic one fracture, impaction of the permanent tooth,

one deformation, amelolastoma and development of s3uamous cell carcinoma or

mucoepidermoid carcinoma/ 89 0he treatment modality indicated for such a cyst is either surgical

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Figure 1: $anoramic vie shoing a radiolucent lesion associated ith a

developing left mandiular 1st premolar and ilateral congenital asence

of mandiular !nd premolars DpreoperativeE

Click here to view

0he contents of the selling ere aspirated and sent for investigations hich revealed thic4

lood mixed mucoid material/ 0he cytopathologic examination of the aspirate shoed mucoid

material, BC, clumps of enign epithelial cells and plenty of cyst macrophages/ A provisional

diagnosis of inflammatory type of dentigerous cyst as made on the asis of the aove findings/

ince oth the mandiular !nd premolars ere missing, it as decided not to enucleate the cyst

along ith the developing 1st premolar/ A preventive approach as folloed to preserve the

developing 1st premolar/ 0herefore, marsupialization of the lesion as planned through the

extracted soc4et of grossly decayed deciduous 1st molar to create a indo alloing continuous

drainage of the cystic content/ $rior to surgery, routine lood and urine examinations ere

carried out, the results ere ithin normal limits/ 0he cyst cavity as pac4ed ith sterile

iodoform gauze to achieve hemostasis and to prevent hematoma formation/ 0he iodoform gauze

as changed on the third day/

Follo-up examination revealed the folloAfter 1 month, there as slight occlusal movement of

the developing tooth ud, ut there as no apparent reduction in the radiolucency 8Figure !9/

After @ months, there as further occlusal movement of the developing tooth and there as a

huge reduction in the radiolucency/ 0he root formation of mandiular left 1st premolar had

started as ell as one formation as evident in the cystic cavity 8Figure "9/

Figure !: $anoramic vie shoing slight occlusal movement of the

tooth ud into the cystic cavity D1 month postoperativeE

Click here to view

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Figure ": $anoramic vie shoing huge reduction in the radiolucent

lesion ith further occlusal movement of the tooth and continuation of

root formation D@ months postoperativeE

Click here to view

After 1! months, there as further occlusal movement of the tooth and there as almost

complete reduction in the radiolucency/ 0he root formation of mandiular left 1st premolar

progressed to one third 8Figure #9/

Figure #: $anoramic vie shoing almost complete ossification of the

ony defect and further occlusal movement of the tooth as ell as

continuation of root formation D1! months postoperativeE

Click here to view

After 1 months, mandiular left 1st premolar had successfully erupted into the oral cavity ith

to-third root formation 8Figure 9/

Figure : $anoramic vie shoing successive eruption of mandiular

left 1st premolar ith complete ossification of the ony defect D1

months postoperativeE

Click here to view

Case 2

A 1.-year-old female patient reported to the %epartment of $edodontics and $reventive dentistry,

ith a chief complaint of selling on right side of the mandile since last !.-! days, hich as

enlarging sloly leading to slight facial asymmetry/ )n general examination, the patient as

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apparently healthy and there as no significant past medical history related to the development

of the selling/

)n extraoral examination, facial asymmetry as seen on right loer side of the face/ 0he

selling as soft at the center surrounded y ony hard elevation/ 0here as no sinus or active

discharge of pus/ 'o lymph node as palpale in this case/

)n intraoral examination, a soft selling ith respect to #!, 7", 7# regions as noted uccally

ith oliteration of uccal vestiule 8Figure @9/ 0here as expansion of uccal cortex around the

selling ut no expansion of the lingual cortex seen on palpation/ 0he selling as smooth

Dapproximately ! G " cm in diameterE ith fluctuation positive at the center on uccal surface

and there as slight moility in #! and 7" regions/

Figure @: (ntraoral photograph of the patient shoing soft fluctuant

selling on right side of mandile

Click here to view

0he )$* revealed an oval-shaped, ell-defined unilocular radiolucency extending from #! to 7#regions ith resorption of roots of deciduous canine and 1st molar/ 0here as mesial

displacement of the root of the mandiular permanent lateral incisor y the radiolucent lesion/

0he permanent canine as displaced to the loer order of the mandile ith the cron pushed

mesially/ 0he developing 1st premolar as displaced distally 8Figure =9/

Figure =: $anoramic vie shoing the radiolucent lesion associated ith

an unerupted right mandiular canine hich as displaced at the loer

order of the mandile DpreoperativeE

Click here to view

0he aspiration of the lesion shoed thic4, stra-colored, oily fluid/ Cytopathologic examination

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of the aspirate revealed mucoid material ith plenty of cyst macrophages/ 0here as no

epithelial cell or malignant cell seen on histopathologic examination/ A provisional diagnosis of

developmental type of dentigerous cyst as made ased on clinical examination and radiological

findings hich as further supported y fine needle aspiration cytology DF'ACE report/

As the size of the radiolucent lesion as large causing mesial displacement of the lateral incisor

and distal displacement of the developing 1st premolar ith mandiular right permanent canine

pushed to the loer order of the mandile, our o2ectives ere to reduce the size of lesion and

to allo formation of ne one/ 0his ould prevent pathologic fracture of the 2a and root

exposure of the lateral incisor if surgical enucleation of the lesion as performed/ 0herefore, at

the initial stage, marsupialization as considered to minimize the damage of the affected teeth

and 2a one/ 0he operation as performed under local anesthesia through the extracted soc4et

of deciduous canine and created a indo alloing continuous drainage of cystic contents/ $rior

to surgery, routine lood and urine examinations ere carried out and the results ere ithin

normal limits/ 0he cyst cavity as pac4ed ith sterile iodoform gauze to achieve hemostasis and

to prevent hematoma formation/ 0he iodoform gauze as changed on the third day/ 0he patients

ere advised to maintain good oral hygiene and a chlorhexidine mouth rinse as prescried for

oth of them/

Follo up examination revealed the folloing/

• After " months, there as sign of healthy one formation on the uccal surface/ (n the

radiograph, the radiolucency had reduced to almost .? and there as change in the

angulation of the permanent mandiular canine from horizontal to a more vertical

direction 8Figure 79/

Figure 7: $anoramic vie shoing huge reduction in the radiolucent

lesion and uprighting of the permanent canine from horizontal to vertical

direction D" months postoperativeE

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Click here to view

• After > months, there as complete reduction in the radiolucent area ith more vertical

uprighting of the canine seen 8Figure >9/

Figure >: $anoramic vie shoing almost complete reduction in the

radiolucent lesion and further uprighting of the permanent canine from

horizontal to vertical direction D> months postoperativeE

Click here to view

• After 1 months, ith minor orthodontic treatment, the tooth had erupted into the oral

cavity 8Figure 1.9 and 8Figure 119/

Figure 1.: $anoramic vie shoing complete reduction in the

radiolucent lesion and the permanent canine ith a onded rac4et D1!

months postoperativeE

Click here to view

Figure 11: (ntraoral photograph shoing erupted permanent canine after

minor orthodontic traction D1 months postoperativeE

Click here to view

%iscussion

0here are to types of dentigerous cysts reported in the literature: developmental and

inflammatory types/ (t is stated that the developmental type of dentigerous cyst is formed around

the cron of an unerupted tooth y accumulation of fluid either eteen the reduced enamel

epithelium and the enamel or in eteen the layers of the enamel organ/ 0his fluid accumulation

occurs as a result of pressure exerted y an erupting tooth on an impacted follicle hich

ostructs the venous outflo and therey induces rapid transudation of serum across the

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capillary all/ 8=9 0he other theory of origin of developmental type dentigerous cyst stated that

the most li4ely origin of the dentigerous cyst is the rea4don of proliferating cells of the

follicle after impeded eruption/ 879 0hese rea4don products result in an increased osmotic

tension and hence cyst formation/ 0he origin of inflammatory type of dentigerous cyst is thought

to e from the overlying nonvital necrotic deciduous tooth, as suggested y Bloch/ 0he resultant

periapical inflammation spreads to involve the follicle of the unerupted permanent successor6 an

inflammatory exudate ensues and results in dentigerous cyst formation/ 8>9 (n this present

investigation, the first case is an inflammatory type of dentigerous cyst originated from the

nonvital primary mandiular 1st molar/ 0he second case is a developmental type of dentigerous

cyst in mandile associated ith a permanent canine elo a vital primary canine/

(n the differential diagnosis, a large periapical cyst, odontogenic 4eratocyst, central giant-cell

granuloma, and unicystic amelolastoma can mimic a dentigerous cyst/ A radiograph does not

differentiate eteen the various types of lesions as mentioned aove hich are associated ith

the root of a nonvital or a vital primary tooth involving the cron of a developing permanent

tooth/ 8>9 0herefore, F'AC and histopathologic examination of the cyst contents and lining is a

must for final diagnosis/ Moreover, the epithelial cells lining the lumen of the dentigerous cyst

possess an unusual aility to undergo metaplastic transition/ arely, some untreated dentigerous

cysts develop into an odontogenic tumor De/g/, amelolastomaE or a malignancy De/g/, oral

s3uamous cell carcinomaE/ 81.9 0o avoid such complications, marsupialization and surgical

enucleation of the cyst lining may e the treatment of choice for such a cyst/

Marsupialization, decompression, and the $artsch operation, all refer to creating a surgical

indo in the all of the cyst, evacuating the contents of the cyst, and maintaining continuity

eteen the cyst and the oral cavity or maxillary sinus or nasal cavity/ (t is a techni3ue that

attempts to relieve intracystic pressure through the creation of an accessory cavity/ 0his

techni3ue is selected since it is a more conservative intervention for the treatment of large cysts,

especially in pediatric dentistry here there is fre3uent proximity of these lesions to the

developing permanent tooth uds/

(n this investigation, the first case as that of a =-year-old oy ho had congenitally missing !nd

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premolars on oth sides of the mandile, hich led us to preserve the affected tooth/ +e had

planned not to enucleate the lesion along ith the developing permanent tooth ut to preserve it

through marsupialization techni3ue/ (n this case, marsupializations only led to successful

eruption of the permanent tooth along ith complete ossification of the ony defects in 1

months/ +e are closely monitoring the patient as he comes from a neary area/ 0here is no sign

or symptom of developing amelolastoma or other malignancy in that area or other parts of the

ody since the last years/ 0he second case as that of a 1.-year-old girl ith a huge

dentigerous cyst involving permanent canine in mandile/ (n this case, initially e had gone for

marsupialization of the cyst through the extracted soc4et of the deciduous canine/ After

considerale amount of one as formed, e had done enucleation of the cyst lining only/ (n this

case, the impacted permanent canine ecame vertical from horizontal position in > months/ 0he

radiolucency of the cystic defect had een completely resolved/ 0his tooth erupted into the oral

cavity after minor orthodontic traction/ 0he successful preservation and eruption of the affected

teeth in this present investigation may e attriuted to the active groth potential and remodeling

of one in children unli4e in adults here 2a groth is completed/

Conclusion

0he old adage A stitch in time saves nine holds true especially in pediatric dentistry here

early diagnosis and proper treatment can save an affected tooth/ Although marsupialization is an

unconventional method of treating dentigerous cyst in adults, it is a very effective method in

treating dentigerous cyst in children here there is alays approximity ith the developing tooth

uds in the 2as/ 0his method is very much useful in treating such cysts hen there are already

congenitally missing teeth for hich e can save the affected teeth for cheing, speech,

maintenance of occlusion and overall health of the groing child/

eferences

1/ (4eshima A, 0amura H/ %ifferential diagnosis eteen dentigerous cyst and enign tumour

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ith an emedded tooth/ 5 )ral ci !..!6##:1"-=/

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dentigerous cyst/ 5 Am %ent Assoc 1>>=61!7:!.1-/

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children/ $ediatr adiol !.."6"":"-@/

8$IBMJ%9 8FILL0J09

#/ 0uzum M/ Marsupialization of a cyst lesion to allo tooth eruption: A case report/

Nuintessence (nt 1>>=6!7:!7"-#/

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7/ 0oller $A/ 0he osmolarity of fluid from the cyst of 2a/ Br %ent 5 1>=.61!>:!=-7/

8$IBMJ%9

>/ Bloch 5K/ %entigerous cyst/ %ent Cosmet 1>!76=.:=.7-11/

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http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12058865&dopt=Abstracthttp://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft2http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft3http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12497227&dopt=Abstracthttp://dx.doi.org/10.1007/s00247-002-0816-2http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft4http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft5http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9522742&dopt=Abstracthttp://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft6http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft7http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft8http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=5272499&dopt=Abstracthttp://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft9http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft10http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft9http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft8http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft7http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft6http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft5http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft4http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft3http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft2http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft1http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12058865&dopt=Abstracthttp://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft2http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft3http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12497227&dopt=Abstracthttp://dx.doi.org/10.1007/s00247-002-0816-2http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft4http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft5http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9522742&dopt=Abstracthttp://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft6http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft7http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft8http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=5272499&dopt=Abstracthttp://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft9http://www.jisppd.com/article.asp?issn=0970-4388;year=2010;volume=28;issue=3;spage=203;epage=208;aulast=Kirtaniya#ft10

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