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

dentition
BC Kirtaniya1, V Sachdev2, A Singla3, AK Sharma4
1

Professor, Department of Pedodontics, Himachal Dental College Sunder Nagar, Himachal


Pradesh, India

Principal, Professor and Head, Department of Pedodontics, Himachal Dental College Sunder
Nagar, Himachal Pradesh, India
3

Professor and Head, Department of Orthodontics, Himachal Dental College Sunder Nagar,
Himachal Pradesh, India

Post Graduate Student, Department of Pedodontics, Himachal Dental College Sunder Nagar,
Himachal Pradesh, India

Date of Web Publication 11-Dec 2010

Abstract
Dentigerous cysts are usually encountered in the practice of pediatric dentistry. The treatment
modalities range from marsupialization to enucleation of the lesion and are based on the
involvement of the lesion with the adjacent structures. However, loss of a permanent tooth in the
management of a dentigerous cyst can be devastating to a child who has already a congenitally
missing tooth. The first case describes the technique of marsupialization in which we extracted
the grossly carious deciduous 1st molar and created a window through the extracted socket to
decompress the lesion. In this case the 2nd premolars were congenitally missing on both sides of
the mandible for which we had not gone for enucleation of the dentigerous cyst along with the
developing 1st premolar. The second case is a developmental type of a big dentigerous cyst
where marsupialization was followed by enucleation of the cystic lining but without removal of
the affected tooth. Both the teeth erupted in the oral cavity.

Keywords: Dentigerous cyst, enucleation, marsupialization, mixed dentition

How to cite this article:


Kirtaniya B C, Sachdev V, Singla A, Sharma A K. Marsupialization: A conservative approach for
treating dentigerous cyst in children in the mixed dentition. J Indian Soc Pedod Prev Dent
2010;28:203-8
How to cite this URL:
Kirtaniya B C, Sachdev V, Singla A, Sharma A K. Marsupialization: A conservative approach for
treating dentigerous cyst in children in the mixed dentition. J Indian Soc Pedod Prev Dent [serial
online] 2010 [cited 2015 Oct 25];28:203-8. Available from: http://www.jisppd.com/text.asp?
2010/28/3/203/73795

Introduction

Dentigerous cysts are the most common of all developmental odontogenic cysts of the jaws and
account for approximately 20-24% of the jaw cysts. They develop around the crown of an
unerupted tooth by expansion of the follicle when fluid collects or a space is created between the
reduced enamel epithelium and the enamel of an impacted tooth. [1] These cysts are always
associated with an unerupted tooth or a developing tooth bud and are found most frequently
around the crown of the mandibular 3rd molars followed, in order of frequency, by the maxillary
canines, maxillary 3rd molars and, rarely, the maxillary central incisors. [2] The cyst may cause
swelling, teeth displacement, tooth mobility and sensitivity if it reaches a size larger than 2 cm in
diameter. [3] In the radiograph, the dentigerous cysts usually show a well-defined unilocular
radiolucency, often with a sclerotic border, surrounding the crown of an unerupted tooth. [2]
Histologically, the dentigerous cyst consists of a fibrous wall lined by non-keratinized stratified
squamous epithelium of myxoid tissue, odontogenic remnants and, rarely, sebaceous cells. [4] If
untreated, these cysts may cause pathologic bone fracture, impaction of the permanent tooth,
bone deformation, ameloblastoma and development of squamous cell carcinoma or
mucoepidermoid carcinoma. [5] The treatment modality indicated for such a cyst is either surgical

removal of the cyst, avoiding damage to the involved permanent tooth, or enucleation of the cyst
along with removal of the involved tooth, or the use of a marsupialization technique. [6] These
cases presented here describe the management of dentigerous cysts in children in the mixed
dentition.

Case Reports

Case 1
A 7-year-old male patient reported to the Department of Pedodontics and Preventive dentistry
with a chief complaint of swelling which was enlarging slowly on left side of mandible since last
1 month, leading to facial asymmetry. The patient gave a history of intermittent pain in that tooth
since more than a year, which used to subside on taking analgesics. On general examination, the
patient was healthy and there was no other bony lesion or defect present in the body. There was
no apparent history of past illness or hospitalization or trauma to the jaw.
On extraoral examination, facial asymmetry was noted on left lower side of the face, with no
sinus or active discharge of pus. The submandibular lymph nodes on the left side of mandible
were enlarged, palpable, tender and mobile, which suggested chronic infection from the tooth.
On intraoral examination, a hard swelling in 73, 74, 75 regions was found with obliteration of the
buccal vestibule. The swelling was bony hard with expansion of the buccal cortex in #73, 74, 75
regions with no expansion of lingual cortex. There was a "typical egg shell cracking" found in
#74 region which was grossly decayed.
In the radiograph [orthopantomograph (OPG)], an oval-shaped, unilocular radiolucency was
noticed around the developing 1st premolar with a radiopaque border. The deciduous 1st molar
was grossly decayed with loss of bone in the bifurcation area. The mesial root of deciduous 2nd
molar was resorbed by the radiolucent lesion. The mandibular 2nd premolars were congenitally
missing on both sides [Figure 1].

Figure 1: Panoramic view showing a radiolucent lesion associated with a


developing left mandibular 1st premolar and bilateral congenital absence
of mandibular 2nd premolars (preoperative)
Click here to view

The contents of the swelling were aspirated and sent for investigations which revealed thick
blood mixed mucoid material. The cytopathologic examination of the aspirate showed mucoid
material, RBC, clumps of benign epithelial cells and plenty of cyst macrophages. A provisional
diagnosis of inflammatory type of dentigerous cyst was made on the basis of the above findings.
Since both the mandibular 2nd premolars were missing, it was decided not to enucleate the cyst
along with the developing 1st premolar. A preventive approach was followed to preserve the
developing 1st premolar. Therefore, marsupialization of the lesion was planned through the
extracted socket of grossly decayed deciduous 1st molar to create a window allowing continuous
drainage of the cystic content. Prior to surgery, routine blood and urine examinations were
carried out, the results were within normal limits. The cyst cavity was packed with sterile
iodoform gauze to achieve hemostasis and to prevent hematoma formation. The iodoform gauze
was changed on the third day.
Follow-up examination revealed the followAfter 1 month, there was slight occlusal movement of
the developing tooth bud, but there was no apparent reduction in the radiolucency [Figure 2].
After 6 months, there was further occlusal movement of the developing tooth and there was a
huge reduction in the radiolucency. The root formation of mandibular left 1st premolar had
started as well as bone formation was evident in the cystic cavity [Figure 3].
Figure 2: Panoramic view showing slight occlusal movement of the
tooth bud into the cystic cavity (1 month postoperative)
Click here to view

Figure 3: Panoramic view showing huge reduction in the radiolucent


lesion with further occlusal movement of the tooth and continuation of
root formation (6 months postoperative)
Click here to view

After 12 months, there was further occlusal movement of the tooth and there was almost
complete reduction in the radiolucency. The root formation of mandibular left 1st premolar
progressed to one third [Figure 4].
Figure 4: Panoramic view showing almost complete ossification of the
bony defect and further occlusal movement of the tooth as well as
continuation of root formation (12 months postoperative)
Click here to view

After 15 months, mandibular left 1st premolar had successfully erupted into the oral cavity with
two-third root formation [Figure 5].
Figure 5: Panoramic view showing successive eruption of mandibular
left 1st premolar with complete ossification of the bony defect (15
months postoperative)
Click here to view

Case 2
A 10-year-old female patient reported to the Department of Pedodontics and Preventive dentistry,
with a chief complaint of swelling on right side of the mandible since last 20-25 days, which was
enlarging slowly leading to slight facial asymmetry. On general examination, the patient was

apparently healthy and there was no significant past medical history related to the development
of the swelling.
On extraoral examination, facial asymmetry was seen on right lower side of the face. The
swelling was soft at the center surrounded by bony hard elevation. There was no sinus or active
discharge of pus. No lymph node was palpable in this case.
On intraoral examination, a soft swelling with respect to 42, 83, 84 regions was noted buccally
with obliteration of buccal vestibule [Figure 6]. There was expansion of buccal cortex around the
swelling but no expansion of the lingual cortex seen on palpation. The swelling was smooth
(approximately 2 3 cm in diameter) with fluctuation positive at the center on buccal surface
and there was slight mobility in 42 and 83 regions.
Figure 6: Intraoral photograph of the patient showing soft fluctuant
swelling on right side of mandible
Click here to view

The OPG revealed an oval-shaped, well-defined unilocular radiolucency extending from 42 to 84


regions with resorption of roots of deciduous canine and 1st molar. There was mesial
displacement of the root of the mandibular permanent lateral incisor by the radiolucent lesion.
The permanent canine was displaced to the lower border of the mandible with the crown pushed
mesially. The developing 1st premolar was displaced distally [Figure 7].
Figure 7: Panoramic view showing the radiolucent lesion associated with
an unerupted right mandibular canine which was displaced at the lower
border of the mandible (preoperative)
Click here to view

The aspiration of the lesion showed thick, straw-colored, oily fluid. Cytopathologic examination

of the aspirate revealed mucoid material with plenty of cyst macrophages. There was no
epithelial cell or malignant cell seen on histopathologic examination. A provisional diagnosis of
developmental type of dentigerous cyst was made based on clinical examination and radiological
findings which was further supported by fine needle aspiration cytology (FNAC) report.
As the size of the radiolucent lesion was large causing mesial displacement of the lateral incisor
and distal displacement of the developing 1st premolar with mandibular right permanent canine
pushed to the lower border of the mandible, our objectives were to reduce the size of lesion and
to allow formation of new bone. This would prevent pathologic fracture of the jaw and root
exposure of the lateral incisor if surgical enucleation of the lesion was performed. Therefore, at
the initial stage, marsupialization was considered to minimize the damage of the affected teeth
and jaw bone. The operation was performed under local anesthesia through the extracted socket
of deciduous canine and created a window allowing continuous drainage of cystic contents. Prior
to surgery, routine blood and urine examinations were carried out and the results were within
normal limits. The cyst cavity was packed with sterile iodoform gauze to achieve hemostasis and
to prevent hematoma formation. The iodoform gauze was changed on the third day. The patients
were advised to maintain good oral hygiene and a chlorhexidine mouth rinse was prescribed for
both of them.
Follow up examination revealed the following.

After 3 months, there was sign of healthy bone formation on the buccal surface. In the
radiograph, the radiolucency had reduced to almost 50% and there was change in the
angulation of the permanent mandibular canine from horizontal to a more vertical
direction [Figure 8].
Figure 8: Panoramic view showing huge reduction in the radiolucent
lesion and uprighting of the permanent canine from horizontal to vertical
direction (3 months postoperative)

Click here to view


After 9 months, there was complete reduction in the radiolucent area with more vertical
uprighting of the canine seen [Figure 9].
Figure 9: Panoramic view showing almost complete reduction in the
radiolucent lesion and further uprighting of the permanent canine from
horizontal to vertical direction (9 months postoperative)

Click here to view


After 15 months, with minor orthodontic treatment, the tooth had erupted into the oral
cavity [Figure 10] and [Figure 11].
Figure 10: Panoramic view showing complete reduction in the
radiolucent lesion and the permanent canine with a bonded bracket (12
months postoperative)
Click here to view
Figure 11: Intraoral photograph showing erupted permanent canine after
minor orthodontic traction (15 months postoperative)
Click here to view

Discussion

There are two types of dentigerous cysts reported in the literature: developmental and
inflammatory types. It is stated that the developmental type of dentigerous cyst is formed around
the crown of an unerupted tooth by accumulation of fluid either between the reduced enamel
epithelium and the enamel or in between the layers of the enamel organ. This fluid accumulation
occurs as a result of pressure exerted by an erupting tooth on an impacted follicle which
obstructs the venous outflow and thereby induces rapid transudation of serum across the

capillary wall. [7] The other theory of origin of developmental type dentigerous cyst stated that
the most likely origin of the dentigerous cyst is the breakdown of proliferating cells of the
follicle after impeded eruption. [8] These breakdown products result in an increased osmotic
tension and hence cyst formation. The origin of inflammatory type of dentigerous cyst is thought
to be from the overlying nonvital necrotic deciduous tooth, as suggested by Bloch. The resultant
periapical inflammation spreads to involve the follicle of the unerupted permanent successor; an
inflammatory exudate ensues and results in dentigerous cyst formation. [9] In this present
investigation, the first case is an inflammatory type of dentigerous cyst originated from the
nonvital primary mandibular 1st molar. The second case is a developmental type of dentigerous
cyst in mandible associated with a permanent canine below a vital primary canine.
In the differential diagnosis, a large periapical cyst, odontogenic keratocyst, central giant-cell
granuloma, and unicystic ameloblastoma can mimic a dentigerous cyst. A radiograph does not
differentiate between the various types of lesions as mentioned above which are associated with
the root of a nonvital or a vital primary tooth involving the crown of a developing permanent
tooth. [9] Therefore, FNAC 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 ability to undergo metaplastic transition. Rarely, some untreated dentigerous
cysts develop into an odontogenic tumor (e.g., ameloblastoma) or a malignancy (e.g., oral
squamous cell carcinoma). [10] To avoid such complications, marsupialization and surgical
enucleation of the cyst lining may be the treatment of choice for such a cyst.
Marsupialization, decompression, and the Partsch operation, all refer to creating a surgical
window in the wall of the cyst, evacuating the contents of the cyst, and maintaining continuity
between the cyst and the oral cavity or maxillary sinus or nasal cavity. It is a technique that
attempts to relieve intracystic pressure through the creation of an accessory cavity. This
technique is selected since it is a more conservative intervention for the treatment of large cysts,
especially in pediatric dentistry where there is frequent proximity of these lesions to the
developing permanent tooth buds.
In this investigation, the first case was that of a 7-year-old boy who had congenitally missing 2nd

premolars on both sides of the mandible, which led us to preserve the affected tooth. We had
planned not to enucleate the lesion along with the developing permanent tooth but to preserve it
through marsupialization technique. In this case, marsupializations only led to successful
eruption of the permanent tooth along with complete ossification of the bony defects in 15
months. We are closely monitoring the patient as he comes from a nearby area. There is no sign
or symptom of developing ameloblastoma or other malignancy in that area or other parts of the
body since the last 5 years. The second case was that of a 10-year-old girl with a huge
dentigerous cyst involving permanent canine in mandible. In this case, initially we had gone for
marsupialization of the cyst through the extracted socket of the deciduous canine. After
considerable amount of bone was formed, we had done enucleation of the cyst lining only. In this
case, the impacted permanent canine became vertical from horizontal position in 9 months. The
radiolucency of the cystic defect had been completely resolved. This tooth erupted into the oral
cavity after minor orthodontic traction. The successful preservation and eruption of the affected
teeth in this present investigation may be attributed to the active growth potential and remodeling
of bone in children unlike in adults where jaw growth is completed.

Conclusion

The old adage "A stitch in time saves nine" holds true especially in pediatric dentistry where
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 where there is always approximity with the developing tooth
buds in the jaws. This method is very much useful in treating such cysts when there are already
congenitally missing teeth for which we can save the affected teeth for chewing, speech,
maintenance of occlusion and overall health of the growing child.

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