PEDIATRIC  DENTAL  JOURNAL  19(2): 240–246, 2009

Case Report

Management of the malposition tooth that was caused by

dentigerous cyst associated with impacted supernumerary
tooth by using an obturator

Mariko Shigeoka, Kenichi Yanagita, Masao Ozaki and Wataru Motokawa

Division of Pediatric Dentistry, Department of Oral Growth and Development, Fukuoka Dental College
2-15-1 Tamura, Sawara, Fukuoka 814-0193, JAPAN

Abstract   This report presents a case of eruption guidance for an upper right Key words
central incisor with a dentigerous cyst associated with an impacted super­ Dentigerous cyst,
numerary tooth in a 5-year-9-month-old boy. A swelling was seen in the region Eruption guidance,
of an upper right central incisor. Radiographic examinations showed that a Obturator,
well-defined cystic lesion, containing an impacted supernumerary tooth crown Supernumerary tooth
in it, was located between the root of the primary upper right central incisor
and a permanent upper central incisor germ. Under general anesthesia, the
dentigerous cyst was removed at extraction of the upper impacted supernu­
merary tooth. And then, a socket was kept open wound. A histopathological
examination confirmed the diagnosis of a dentigerous cyst associated with a
supernumerary tooth. By using an obturator, we guided eruption of an upper
right central incisor with malposition that was caused by the dentigerous cyst,
and observed the way of the tooth eruption for two years and seven months.
The obturator was inserted in the socket directly for three months until it was
closed. After that, the obturator was used as only a removable space maintainer.
Eight months after the operation, the obturator was removed because the upper
left central incisor began to erupt. Two years and seven months after the opera-
tion, both upper central and lateral incisors had erupted completely. In this
case, the obturator was used for expectation of natural eruption of permanent
incisors, space maintenance and aesthetic recovery. The permanent incisors
had been able to be guided to almost correct position without traction.

Introduction some difficulties to do those treatments in pediatric

Dentigerous cysts are often encountered in daily
clinical practice by pediatric dentists, and appear
frequently in the regions of the mandibular pre­
molars, upper incisors, and mandibular wisdom teeth.
But it was reported that dentigerous cysts associated
with supernumerary teeth are rare. Moreover, in
younger children, the report of the dentigerous cyst
associated with supernumerary teeth is fewer1–5). In
these cases, dentigerous cysts should be removed
or be marsupialized for treatment. However it has
Received on April 13, 2009
Accepted on July 1, 2009
240
dentistry, because some patients are uncooperative
for earlier age, or some patients in mixed dentition
period needing eruption guidance. Nevertheless it is
necessary to treat correctly with those cases in order
to develop the normal permanent dentition.
In this case, we treated a 5-year-9-month-old
boy with a dentigerous cyst caused by an impacted
supernumerary tooth. The dentigerous cyst was
removed at extraction of the upper impacted super-
numerary tooth, and the socket was kept open wound.
By using the obturator, we guided eruption of the
upper right central incisor with malposition caused
by dentigerous cyst. And then we observed for two
years and seven months.
 Management of the malposition tooth  by using an obturator 241

Fig.  1  X-ray examination

(A) Panoramic radiography, (B) Periapical radiography

Fig. 2 Photograph in the first visit

Case Report Oral findings

A 5-year-9-month-old boy was referred to Fukuoka
Dental College Hospital Department of Pediatric
Dentistry from another dental office for examination
of swelling in the region of upper right central incisor
on February 12, 2006. His primary upper left central
incisor and already erupted supernumerary tooth
were extracted at that dental office before reference
to our department on July 8, 2005. Afterwards, he
took a painless swelling in the region of an upper
right central incisor. Finally the dentigerous cyst and
another impacted supernumerary tooth had been
suspected as a result of the X-ray examination on
January 30, 2006 (Fig. 1A, 1B).
Small swelling was found in the gingival area at the
apical point of primary upper right central incisor.
It was Parchment-like by the palpation (Fig. 2).
X-ray findings
The cyst surrounded the upper median impacted
supernumerary tooth crown. The root of primary
upper right central incisor was resorbed like circular
arc (Fig. 1A, 1B). The upper left central incisor
was excluded up by the cyst. The maxilla showed
swelling at the labial and palatal side. The cortical
bones were thin (Fig. 3A). The upper left central
incisor and the upper right lateral incisor were very
near the cyst, and were pushed aside to distal side
242 Shigeoka, M., Yanagita, K., Ozaki, M. et al.

Fig. 3 Dental CT in the first visit

(A) Sagittal plane,
(B) Coronal plane,
(C) Transverse plane

Fig.  4  Photographs during operation

(A) Thin cortical bones, (B) The removed cyst, (C) Dentigerous cyst with a supernumerary tooth,
(D) Incisal edge of the upper right central incisor, (E) The socket after suture, (F) Drainage

with torsiversion (Fig. 3B, 3C).
Treatment
Surgical operation was performed under general
anesthesia. The primary upper right central incisor
was extracted. The dentigerous cyst and the impacted
supernumerary tooth which had incomplete root were
removed together (Fig. 4A, 4B, 4C). The socket of
the extracted tooth was kept open wound (Fig. 4D,
4E, 4F). Next day, an obturator was inserted to the
 Management of the malposition tooth  by using an obturator 243

Fig.  5  An obturator and oral photographs on it

(A, B) An obturator, (C) Front view, (D) Palatal view

Fig. 6 Pathological examination

(A)×100, (B)×400

socket for eruption guidance of an impacted central
incisor with malposition (Fig. 5A, 5B, 5C). After
the stitches had been removed, we did the passage
observation while adjusting the obturator every month
until the dislocated tooth came to erupt.
Histopathology
The impacted tooth crown was included in the cyst.
The enucleated cyst wall was submitted to histo­
logical examination. The cyst was composed of
the fibrous connective tissues with some squamous
epithelial linings. The inside of the cyst walls
were covered with some non-keratinized stratified
squamous epithelial cells. The fibrous connective
tissues were admitted under the epithelial lining, and
the boundary with the epithelial lining was smooth
and plain. The fibrous connective tissues were rough
in the epithelial side, and those were dense in the
other side. There were some lymphocyte cells in the
fibrous connective tissues, but inflammatory cellular
infiltration in epithelium of dentigerous cyst was not
admitted (Fig. 6A, 6B). If the cyst associated with
244 Shigeoka, M., Yanagita, K., Ozaki, M. et al.

Fig.  7  Dental X-ray in the periodic observation

(A) One month after, (B) Eight months, (C) One year and three months, (D) One year and nine months,
(E) Two years and three months, (F) Two years and seven months

apical inflammation of the treated primary tooth, the

lining epithelium should have showed infiltration of
inflammatory cells mainly composed of lymphocyte
and plasma cells6). In this case, though the primary
upper right central incisor near the cyst was given
root canal treatment, infiltration of inflammatory cells
was not confirmed. The histopathological findings
confirmed the diagnosis of a dentigerous cyst asso­
ciated with an impacted supernumerary tooth.

Postoperative progress
One month after the operation, the upper right central
incisor was located supraversion in the alveolar bone
though there was still big space between the upper Fig. 8 Photograph in two years and seven months after
central incisors (Fig. 7A). The obturator was grinded the operation
because upper labial frenum has slightly inflamma-
tion. Three months after the operation, the socket
was closed. The obturator was grinded completely bone. The obturator was removed because the upper
and used as only a removable space maintainer. left central incisor began to erupt (Fig. 7B). One year
Eight after the operation, the upper right central and three months after the operation, the upper right
­incisor was heading to mesial side in the alveolar central incisor began to erupt, too (Fig. 7C). Until
 Management of the malposition tooth  by using an obturator
one year and nine months after the operation, both
upper central teeth had no difference in the vertical
position (Fig. 7D). The screw expansion plate was
used to make space in two years and three months
after the operation because there was not enough
space for permanent dentition (Fig. 7E). Two years
and seven months after the operation, both upper
lateral incisors had erupted completely (Figs. 7F, 8).
Discussion
A dentigerous cyst is a developmental odontogenic
cyst which originates through alterations of the
reduced enamel epithelium in an unerupted tooth
after the crown has been fully formed. Most of typical
examples are those associated with the third molar
teeth of the mandible, followed by maxillary canines
and premolars of both maxilla and mandible. Although
the ratio of supernumerary teeth is not low among
impacted teeth, only a few cases on the association
of dentigerous cysts with supernumerary teeth have
been reported. Supernumerary teeth constitute about
5–6% of all dentigerous cysts. Approximately 95%
of dentigerous cysts involve the permanent dentition,
and approximately 5% are associated with supernu-
merary teeth1). It is said that supernumerary teeth are
seldom to associate with dentigerous cysts, which
are not common in the first decade of life1,2,5,7).
­Generally, if the operation itself would not cause
postoperative morbidity, dentigerous cysts should
be enucleated8,9). Large dentigerous cysts should be
marsupialized if enucleation and tooth removal might
result in the destruction of the nerve and blood
­supply to adjacent teeth. Because the teeth involve
adjacent anatomic structures, such as the maxillary
sinus, the nasal cavity, or the orbital cavity, involve
major neurovascular bundles, such as the inferior
alveolar one, or possibly result in the fracture of the
mandible. Almost, dentigerous cysts, large or small,
that contain the crowns of teeth which can serve a
useful purpose should be marsupialized, and with
orthodontic aid the teeth should be moved into the
dental arch in pediatric dentistry10–12).
In this case, the dentigerous cyst caused perma-
nent teeth germ malposition. After the removal of the
dentigerous cyst and the impacted supernumerary
tooth, the obturator was used for eruption guidance
of the permanent incisors. In such a case, although
a drain might was usually selected, we would select
not a drain but an obturator because of the following
reasons; (1) It was only difficult for the children
245
to go to hospital regularly many times for a drain
exchange. (2) Aesthetic recovery was necessary to
the premature loss of the primary central teeth. (3)
The patient and his family were cooperative. And
then, we had observed the permanent teeth with
malposition that was caused by the dentigerous cyst
for two years and seven months. Usually, in using a
drain, the patient needed to go to hospital regularly
every two or three days for exchange the drain until
the socket would be closed. But in this case, for three
months while the obturator was inserted in the socket,
the patient needed to go to the hospital only once a
month. We told the patient to use the obturator as
usual removal space maintainer, to wear all day long
and keep it clean. It is thought that an obturator
has the following merits; (1) A drain exchange is
unnecessary because the obturator can be inserted
in the socket directly. (2) An obturator is made after
impression taken, so it hardly gives the sense of
incongruity. (3) It can be easily treated relatively. (4)
An obturator has both functions of space mainte-
nance and aesthetic recovery together. On the other
hand, it has some difficulties with adjustment of an
obturator and cooperation of the patient13,14). And
also it is very important to be cared enough with
an obturator at home in order not to get infection.
Though an obturator has some demerits like this, it
is thought that an obturator is suitable for eruption
guidance of impacted permanent teeth in mixed
dentition period. In this case, the obturator was used
for expectation of natural eruption of permanent
incisors, and the permanent incisors were able to be
guided to almost correct position without traction.
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