1997;128;201-205J Am Dent Assoc VB Ziccardi, TI Eggleston and RE Schneiderdentigerous cystUsing fenestration technique to treat a large

jada.ada.org ( this information is current as of May 12, 2011):The following resources related to this article are available online at

http://jada.ada.org/content/128/2/201in the online version of this article at:

including high-resolution figures, can be foundUpdated information and services

http://www.ada.org/prof/resources/pubs/jada/permissions.aspthis article in whole or in part can be found at:

of this article or about permission to reproducereprintsInformation about obtaining

© 2011 American Dental Association. The sponsor and its products are not endorsed by the ADA.

on May 12, 2011

jada.ada.orgD

ownloaded from

U

TO TREAT A LARGE DENTIGEROUS CYSTVINCENT B. ZICCARDI, D.D.S., M.D.; TODD 1. EGGLESTON, D.D.S.; RONALD E. SCHNEIDER, D.D.S.

0he dentigerous cyst is thesecond most common type ofodontogenic cyst found, afterthe radicular cyst. Clinically, itis often asymptomatic; it is dis-covered as an incidental radio-graphic finding or when acuteinflammation or infection devel-ops.1 It can, however, becomeextremely large and is some-times associated with corticalexpansion and erosion.2

The dentigerous cyst is al-ways associated with anunerupted or developing tooth,and is found most frequentlyaround the crowns of mandibu-lar third molars, followed bymaxillary canines and thenmaxillary third molars. It haseven been reported, albeitrarely, in association with im-pacted deciduous teeth.3 Malepatients are slightly more likelyto develop dentigerous cyststhan are female patients.3

Development of dentigerouscysts in animals also has beenwell-documented.4

This article describes use offenestration technique to treata large and expansile dentiger-ous cyst in an adolescent boy.

Dentigerous cysts are commonly

encountered In the practice of

dentistry and oral and maxillofa-

cial surgery. Treatment modali-

ties range from enucleation to

marsupialization, and are based

on the premise that the patho-

logical process can be controlled

locally with minimal injury to the

adjacent host structures. In a

child, however, loss of perma-

nent tooth buds in the manage-

ment of a large dentigerous cyst

can be devastating. This article

describes the technique of fen-

estration, which removes this

entity and preserves the devel-

oping dentition.

CASE REPORT

A 8-year-old boy was referred toan oral and maxillofacialsurgery clinic for consultationregarding an asymptomatic ex-

pansion of the right mandible.The boy's mother mentioned theenlargement to her son's pedia-trician during a well-child visitshortly after she had noticed it.The physician prescribed an an-tibiotic regimen and referredthe child to an oral and maxillo-facial surgeon when the lesiondid not diminish in size aftertwo weeks.

Clinical examination re-vealed an expansion in the rightmandibular vestibule coveredby healthy-appearing and freelymovable mucosa that extendedfrom the permanent first molarto the ipsilateral deciduous lat-eral incisor (Figure 1). The pa-tient reported no pain duringpalpation, and the oral andmaxillofacial surgeon did notnote any neurosensory deficits.The expansion was firm, al-though some crepitus was de-tected when the surgeon palpat-ed over the height of theswelling.

Radiographic studies detect-ed a large unilocular lesion withinvolvement of the developingbicuspids and canine (Figure 2).An occlusal radiograph showed

JADA, Vol. 128, February 1997 201

on May 12, 2011

jada.ada.orgD

ownloaded from

-CLINICAL PHACTICE

Figure 1. Initial firm enlargement in right mandibular Figure 2. Initial panoramic radiograph revealing dis-vestibule of an 8-year-old boy with normal-appear- placed tooth buds and large unilocular radiolucency.ing mucosa.

LC

Figure 3. Occlusal radiograph revealing buccal cor-tical expansion with intact lingual cortex.

Figure 4. Extraction sites of deciduous molars ex-tended into the cystic cavity.

a large radiolucency with nor-mal lingual cortex (Figure 3)and a thin, expanded buccalcortex. The cystic structure ap-peared to originate from thefirst bicuspid with distal and in-ferior displacement of the sec-ond bicuspid. A clinical diagno-sis of a dentigerous cyst wasmade at this time.

Several treatment options ex-isted, including- removal of the cyst via enu-cleation;- marsupialization of the cystto the oral mucosa, with place-ment of a wire to allow fordrainage and decompression ofthe cyst;

- decompression of the cyst viafenestration.

Enucleation carries with it arisk that the developing toothbuds could be lost, which wouldnecessitate reimplantation. Therisk of injuring or losing thetooth buds was deemed too sig-nificant for removal of the cystvia enucleation. Fenestrationwould allow for decompressionof the cyst with preservation ofthe developing dentition. In ad-dition, time would allow for con-tinuous root development andsome bone fill as the decompres-sion evolved. Finally, the fenes-tration technique allows forguided eruption of the develop-

ing teeth as the overlying cysticstructure is decompressed.

With the patient under theinfluence of general anesthesia,the surgeon inserted a large-gauge needle and aspirated ap-proximately 5 cubic centimetersof a straw-colored fluid from theswelling. Cholesterol crystalswere suspended in the sample,and a small amount of bloodtinged the specimen at the endof the aspiration.An incision was made along

the gingival crevice, and a full-thickness mucoperiosteal flapwas gently elevated off the ex-pansion in a subperiostealplane, maintaining the bony

202 JADA, Vol. 128, February 1997

,ML

b,"W

4f 1

on May 12, 2011

jada.ada.orgD

ownloaded from

CLINICAL PRACTICE

cortex. The surgeon extractedthe deciduous molars, whichwere mobile, and enlarged thesocket site to form a bony win-dow (Figure 4). Creation of thewindow allowed the surgeon tosee a very thick and fibrous-ap-pearing cyst wall, the visibleportion of which was excisedand submitted for pathologicalidentification. Care was takento avoid disturbing the develop-ing tooth buds.

Into this bony window, thesurgeon inserted a section of in-travenous tubing that had beenheated and flattened on each end(Figure 5). Placement of the tubewas secured with silk ligatures(Figure 6). The wound then wasclosed, and after surgery, the pa-tient was instructed to irrigatethe cystic space through this fen-estration tube at least twice eachday with sterile saline.

Histologic diagnosis con-firmed that the lesion was adentigerous cyst. One monthafter the surgery, an impressionwas made of the area and aspace maintainer was cementedbetween the permanent firstmolar and the deciduous ca-nine.

Radiographs taken eightmonths after surgery indicatedcontinued root formation anderuption of the developing per-manent dentition with apparentbone fill taking place beneaththe developing teeth (Figure 7).At this examination, the dentistnoted that the deciduous caninewas fairly mobile and that ifthis tooth exfoliated, spacemaintenance would require alingual arch device, whichwould be more complex thanthe method that was beingused. To avoid this complica-tion, a second surgery was per-formed to expose the bicuspidteeth, therefore aiding in their

eruption. Ten months after theinitial surgery, eruption of thefirst bicuspid could be seen on aradiograph (Figure 8).

DISCUSSION

Dentigerous cysts develop froman accumulation of fluid be-tween remnants of the enamelorgan and the dental crown.The expansion is related to anincrease in the osmolality re-sulting from passage of inflam-matory cells and desquamatedepithelial cells into the cysticlumen. (Pericoronal radiolucen-cies that exceed 2.5 to 3.0 mil-limeters are considered to becystic.)

I Since dentigerous

cysts oAtn are asymp-omatc, the poenial

exists for the sur-rounding stmctures to

suffer damage befo-e

the cyst is detected.

An intrafollicular spread ofperiapical inflammation from adeciduous tooth also may resultin the development of adentigerous cyst. These cystscan be referred to as inflamma-tory dentigerous cysts.5

Dentigerous cysts have thepotential to resorb and expandinto the surrounding tissue anddisplace bone and tooth roots aswell as cause tooth displace-ment, malocclusion or facialasymmetry. In general, howev-er, most dentigerous cysts arepainless and are found as inci-dental radiographic findings.6

The controversy surroundingremoval of impacted teeth, es-pecially third molars, is in partbased on the risk that adentigerous cyst could develop.

Figure 5. Intravenous tubingfashioned into a drain by heatingand flattening the ends.

Some authors argue that the ex-pense of treating and potentialmorbidity of these lesions ex-ceeds the benefit of prophylactictooth removal when a patient isyoung and healthy.78 The devel-opment of these cysts may takeyears; therefore, more precisemarkers of potential cystic de-velopment need to be elicitedbefore absolute advocation forthe removal of all asymptomaticimpacted teeth can be made.78

Since dentigerous cysts oftenare asymptomatic, the potentialexists for the surroundingstructures to suffer damage be-fore the cyst is detected. Somecomplications of dentigerouscysts that have gone undetectedinclude secondary infection withdestruction of adjacent struc-tures or metaplastic change ofthe cyst to a more aggressive le-sion, including a malignantone.9

The epithelial cells lining thelumen of dentigerous cysts areable to undergo metaplasticchange to other epithelial celltypes. The cyst's lining maycontain areas of orthokera-tinization, ciliated cells ormucin-secreting cells. Becauseof this inherent ability for meta-plastic change, some dentiger-

JADA, Vol. 128, February 1997 203

on May 12, 2011

jada.ada.orgD

ownloaded from

-CLINICAL PHACTICE

Figure 6. Immediate postoperative view with l.V.tubing sutured in place.

rigure ff. E-anoramic EauLograpEE a1c eiUgmUonEEsafter surgery with evidence of bony fill apical totooth no. 28.

Figure 8. Radiograph taKen 1o monthtial surgery showing the eruption of kand development of apical bony fill.

ous cysts appear to progress tomore aggressive lesions such asan odontogenic keratocyst,ameloblastoma, mucoepider-moid carcinoma or squamouscell carcinoma.10

The histopathologic findingsof dentigerous cysts vary de-pending on whether the cyst isinflamed. In the noninflamedvariant, the fibrous connectivetissue wall is loosely arrangedwith small islands of inactiveodontogenic epithelial rests.The epithelial lining consists ofa few layers of cuboidal strati-fied squamous epithelium witha flat epithelial tissue-connec-

tive tissue in-terface. The in-flameddentigerouscyst has adenser connec-tive tissuelayer with a

both premchronic inflam-matory cell in-filtrate. Theepithelial lin-ing of the in-flamed cyst

is after the exi-may becomebooth premolars hyperplastic

with the for-mation of rete

ridges and a keratinized sur-face. Mucous cells, sebaceouscells and ciliated epithelial cellsalso may be present in this cyst.These elements represent themultipotentiality of the epithe-lial lining of dentigerous cysts,which must be examined micro-scopically to rule out metaplas-tic or neoplastic changes.11

Various imaging techniquescan indicate whether dentiger-ous cysts have caused bonechanges. The anatomy and rela-tionship of the dental apexeswith the adjacent bone can beevaluated with intraoral dentalviews. Maxillary and mandibu-

lar occlusal views also can de-lineate the entire respectivearch and reveal any buccal orlingual expansion. Panoramicradiographs are a useful firstline film in that they provide asurvey of the entire mandibleand a portion of the maxilla.Nonintraoral radiographs pro-vide a good view of the ramus,angle and body of the mandible.Posteroanterior and obliqueviews are useful in this regard.

In select cases, computed to-mography, or CT, is a helpfulmodality, especially for assess-ments of large lesions. Axialsections can demonstrate buccaland lingual surfaces and candefine areas of expansion anderosion. Coronal sections areuseful in demonstrating lesionsof the maxilla and palate. TheCT examination should includeboth bony- and soft-tissue win-dows. Magnetic resonanceimaging, or MRI, has limitedapplication for most mandibularlesions. It may, however, pro-vide information on the chara¢-ter of fluid within a cyst-forexample, keratin, blood or thepresence of solid forms.12

Surgical treatment ofdentigerous cysts usually in-cludes enucleation with removal

204 JADA, Vol. 128, February 1997

on May 12, 2011

jada.ada.orgD

ownloaded from

CLINICAL PRACIICE

of the causative impacted tooth.An alternative treatment ismarsupialization, which re-quires the surgeon to make anopening at the lowest point ofthe cystic cavity. Marsupial-ization is hard to rely on whentreating a dentigerous cyst be-cause it is difficult to maintainpatency in a bony lesion. Also, alateral window could drive thedeveloping permanent dentitiontoward ectopic eruption, result-ing in malocclusion and creat-ing a potential need for furtherinterceptive orthodontics. Anopening along the crest, as usedin the described case, woulddrive the permanent teeth to-ward their correct eruptionpaths.'3

The technique of fenestrationwas used in this case to aid inthe correct development anderuption of the permanent den-tition. A drain fashioned fromIV tubing is easily placed intothe cystic cavity from which aspecimen has been removed forhistologic identification. Thisdrain is readily secured withsilk ligatures, can be easilycleaned and allows a distinctport through which the patientcan irrigate the cystic cavitydaily. In addition, the drain isjust visible radiographically sothat its position relative to theerupting teeth can be followed,and the drain can be removed

or repositioned should it en-croach on the erupting dentition.

In this case, a simple spacemaintainer allowed the appropri-ate space for the eruption ofthebicuspid teeth. The fenestrationtechnique, as described here,simplified the surgical treatmentof the cyst and offered the great-est chance for maintaining thedeveloping dentition. The onlycaution is that a second minorprocedure may be required to re-move any residual cystic matteror to uncover emerging teeth toaccelerate their eruption.

CONCLUSION

This case report illustrates asimplified surgical treatment fora large dentigerous cyst in anadolescent in the mixed denti-tion stage. The procedure can beperformed in the office and pro-vides the best chance to pre-serve and maintain the develop-ing dentition for eruption into anormal occlusion. The tech-nique, however, does requireclose observation on the part ofboth the patient and treatingdoctor. The result can be elimi-nation of the pathology andmaintenance of dentition withminimal surgical intervention. .

Dr. Ziccardi is an assistant professor,Mount Sinai School of Medicine, Departmentof Oral and Maxillofacial Surgery, ElmhurstHospital Center, Building H2-82, 79-01Broadway, Elmhurst, N.Y. 11373. Addressreprint requests to Dr. Ziccardi.

Dr. Eggleston is a senior resident, MountSinai School of Medicine, Department of Oraland Maxillofacial Surgery, Elmhurst HospitalCenter, Elmhurst, N.Y.

Dr. Schneider is an assistant professor,Mount Sinai School of Medicine, Departmentof Oral and Maxillofacial Surgery, ElmhurstHospital Center, Elmhurst, N.Y.

1. Bux P, Lisco V. Ectopic third molar asso-ciated with a dentigerous cyst in the sub-condylar region: report of a case. J OralMaxillofac Surg 1994;52:630-2.

2. Daley TD, Wysocki GP. The smalldentigerous cyst. A diagnostic dilemma. OralSurg Oral Med Oral Pathol Oral RadiolEndod 1995;79(1):77-81.

3. Boyczuk MP, Berger JR. Identifying a de-ciduous dentigerous cyst. JADA 1995;126:643-4.

4. Gardner DG. Dentigerous cyst in ani-mals. Oral Surg Oral Med Oral Pathol1993;75:348-52.

5. Murakami A, Kawabata K, Suzuki A, etal. Eruption of an impacted second premolarafter marsupialization of a large dentigerouscyst: case report. Pediatr Dent 1995;17:372-4.

6. Miller CS, Bean LR. Pericoronal radiolu-cencies with and without radiopacities. DentClin North Am 1994;38(1):51-61.

7. Girod SC, Gerlach KL, Kreuger G. Cystsassociated with long-standing impacted thirdmolars. Int J Oral Maxillofac Surg 1993;22(2):110-2.

8. Carl W, Goldfarb G, Finley R. Impactedteeth: prophylactic extractions or not? N YState Dent J 1995;61(1):32-5.

9. Falcone F, Lazow SK, Berger JR, GoldBD. Superior orbital fissure syndrome sec-ondary to infected dentigerous cyst of themaxillary sinus. N Y State Dent J1994;60(9):62-4.

10. Johnson LM, Sapp JP, McIntire DN.Squamous cell carcinoma arising in adentigerous cyst. J Oral Maxillofac Surg1994;52:987-90.

11. Waldron CA. Odontogenic cysts and tu-mors. In: Neville BW, Damm DD, Allen CM,Bouquot JE, eds. Oral and maxillofacialpathology. Philadelphia: Saunders; 1995:493-6.

12. Weber AL. Imaging ofcysts and odonto-genic tumors ofthe jaw. Definition and classifi-cation. Radiol Clin North Am 1993;31(1):101-20.

13. Clauser C, Zuccati GK, Barone R,Villano A. Simplified surgical-orthodontictreatment of a dentigerous cyst. J ClinOrthod 1994;28(2):103-6.

JADA, Vol. 128, February 1997 205

on May 12, 2011

jada.ada.orgD

ownloaded from