|Year : 2014 | Volume
| Issue : 2 | Page : 49-52
Conservative surgical management of a dentigerous cyst associated with an impacted mandibular canine
Ashfaq Yaqoob1, Tariq Majid Wani2, Junaid Ashraf3, Gowhar Yaqoob4, Nusrat Yaqub5
1 Department of Prosthodontics, Government Dental College, Srinagar, Jammu and Kashmir, India
2 King Fahad Medical City, Riyadh, Saudi Arabia
3 Department of OMFS, Government Dental College, Srinagar, Jammu and Kashmir, India
4 Department of OM and R, Government Dental College, Srinagar, Jammu and Kashmir, India
5 PGDO and G Ultrasonography, PSM Medical city, Riyadh, Saudi Arabia
|Date of Web Publication||21-Oct-2014|
Deparment of Prosthodontics, Govt Dental College, Srinagar, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Dentigerous cyst or follicular cyst is an odontogenic cyst with the crown of an impacted, embedded, unerupted, or developing tooth. It is the second most common odontogenic cyst associated with an impacted, embedded, unerupted, or developing tooth. A case of large dentigerous cyst associated with an impacted canine in the mandible. This case is of interest due to its extensiveness and the presence of an impacted canine in the mandible. The purpose of this report was to describe the successful outcome of conservative surgical management of a large dentigerous cyst associated with an impacted mandibular canine. Treatment modalities range from enucleation to marsupalization which is influenced by the age of the patient, severity of impaction, size of the cyst, and root formation of associated tooth/teeth.
Keywords: Dentigerous cyst, follicular cyst, impacted canine, odontogenic cyst
|How to cite this article:|
Yaqoob A, Wani TM, Ashraf J, Yaqoob G, Yaqub N. Conservative surgical management of a dentigerous cyst associated with an impacted mandibular canine. Dent Med Res 2014;2:49-52
|How to cite this URL:|
Yaqoob A, Wani TM, Ashraf J, Yaqoob G, Yaqub N. Conservative surgical management of a dentigerous cyst associated with an impacted mandibular canine. Dent Med Res [serial online] 2014 [cited 2020 Aug 15];2:49-52. Available from: http://www.dmrjournal.org/text.asp?2014/2/2/49/143333
| Introduction|| |
Dentigerous cyst or follicular cyst is a benign noninflammatory odontogenic cyst that is thought to be developmental in origin and account for about 16.6% of all such jaw lesion. , It is the second most common odontogenic cyst associated with the canine of an impacted, embedded, unerupted, or developing tooth. They usually present in the second to fourth decade of life and are rarely seen in childhood because they almost exclusively occur in secondary dentition. ,, Over 75% of all cases are located in the mandible with the most common involved teeth being. ,
- Mandibular third molar (most common)
- Maxillary third molar (second most common)
- Maxillary canine
- Mandibular second premolar
- Very rarely, it involves the mandibular canine and in the ration of maxillary to mandibular canine associated with cyst is 20:1. , Males are slightly more likely to develop than females. ,
It is formed by the hydrostatic pressure exerted by the accumulation of fluid between reduced enamel epithelium and tooth crown of unerupted teeth/tooth. ,,
They are usually asymptomatic and discovered during routine radiographic examination, however, they may be large and result in a palpable mass, as they grow they displace adjacent teeth.  The radiographic feature is characterized by a symmetric well-defined unilocular radiolucent lesion surrounding the crown of an unerupted tooth generally. There is a distinct dense periphery of reactive bone (condensing osteitis) with a radiolucent center. They are generally treated by surgical means. The most common surgical modalities used are total enucleation,  marsupialization, , and decompression of the cyst via fenestration.  These cysts can also manifest as multilocular entities and occasionally may be associated with the resorption of roots of adjacent erupted teeth. ,,
| Case report|| |
A 23-year-old male patient presented with the chief complaint of a swelling on the right side of the lower jaw since 3 months [Figure 1]. The swelling had been growing slowly over the period and was associated with no pain or discharge. The overall general physical health was good with nonspecific general medical history.
The extraoral examination revealed a gross facial asymmetry on the right side of the lower jaw. There was no sign of any regional lymphadenopathy. A hard nontender swelling was seen on the right side of lower vestibule from the distal aspect of first premolar to ipsilateral central incisor. There was missing right permanent canine but retained right deciduous canine in the mandible [Figure 2]. The overlying mucosa was normal with no signs of inflammatory or serosanguineous discharge. The swelling was associated with expansion of buccal and lingual cortical plates. The teeth adjacent to the swelling were firm and not associated with decay. On palpation, eggshell cracking sound was produced and on aspiration, clear yellowish fluid present [Figure 3].
A panoramic radiographic examination revealed that there was a well-circumscribed unilocular radiolucency in the body of the mandible on the right side associated with the crown of an impacted canine and lesion surrounded by a radiopaque line and impacted tooth was developed completely.
| Treatment|| |
Aims and objectives
Considering the age of the patient, his occlusal status, size of the cyst, position and developmental stage of the root of the involved teeth, a conservative treatment modality was decided upon. The main objectives of the treatment were the clinical and radiographic elimination of the pathological entity.
Under local anesthesia, mandibular retained right canine, mandibular right first premolar, and second premolar were extracted, and the socket was used to establish a communication between the cyst cavity and oral cavity [Figure 4] and [Figure 5]. First, marsupialization was performed, and the gauze pack was placed in the cavity which was impregnated with soframycin paste. The pack was left inside for a period of 14 days and secured by sutured. Patient was given a week course of antibiotic and analgesic and was asked to return for the follow-up once in 15 days and advised constant irrigation of the cavity with mouth wash. Periodic radiographic evaluation was done and after a period of 6 months, when the cyst became smaller, enucleation was performed along with extraction of impacted canine and the wound was sutured after irrigation. The suture was removed after 1 week and regular follow-up once in 15 days. The specimen was sent for histopathological examination and the report come back as a mandibular canine encased by a cyst lined by a nonkeratinized stratified squamous epithelium with dystrophic calcification and clusters of mucous cells found within the cyst. After 7 months, intraoral swelling healing was normal, and no evidence of bone resorption or radiolucent lesion was observed [Figure 6] and [Figure 7]. The patient was advised for prosthetic rehabilitation.
| Discussion|| |
The dentigerous cyst is the most common type of the noninflammatory odontogenic cyst and the most common cause of a pericornal area of radiolucency associated with an impacted tooth.  Diagnosis can be made by careful clinical, radiographical, and histological examination.
Failure of eruption of the mandibular canine is an unusual event.  Mandibular canine impaction is regarded as a much rarer phenomenon, and there are limited numbers of studies revealing its frequency of occurrence. 
Grover and Lorton found only 11 impacted canine (0.22%) in the mandible in 5000 individuals.  Chu et al. reported five mandibular impacted canine (0.07%) teeth in 7486 patients.  A study by Rohrer examined 3000 patients, radio graphically found 62 impacted maxillary canine (0.1%), a ratio of 20:1.  Another study by Aydin et al. involving 4500 Turkish patients, the incidence of mandibular canine impaction was 0.44%. 
The aim of treatment for dentigerous cyst is a complete elimination of pathology and maintenance of dentition with minimal surgical intervention. Recently defined criteria for selecting the treatment modality refer to the cyst size and location of the cyst, patient age, dentition involved, stage of root development, position of the involved tooth within the jaw and its relation to the adjacent teeth, and the involvement of adjacent vital structures. 
The method of surgical approach includes extraoral and intraoral approach. The most commonly used extraoral approach was submandibular and preauricular access. The external access has the advantage of good exposure of the surgical site but may result in complications, such as extraoral scar formation, damage of joint components, facial nerve injury in case of preauricular access or damage of marginal mandibular branch of the facial nerve in case of submandibular access. The intraoral approach may avoid the problems but provides a small surgical site.
Surgical treatment of dentigerous cyst usually includes marsupialization and enucleation along with or without the extraction of the impacted tooth. Enucleation of the lesion along with or without removal of associated ,,,, is done when the cyst is small, no vital adjacent structures, tooth, not in a favorable position, need accelerated healing, and no recurrence. Enucleation with alter the normal tooth development and in certain circumstances especially in children, the involved tooth should be given a chance to erupt and large cyst if enucleated result in pathological fractures and damage to the viral structures and tooth buds also.
Marsupialization is done in cases when the size of the cyst is large, in a young patient with developing tooth gums, in elderly, debilitated patient, cyst proximity to the vital structures if the tooth is in a favorable position and space is available, it will permit the eruption of unerupted tooth. Major disadvantages of marsupialization are that the pathological tissue is left in situ without through histological examination, prolonged follow-up visits, prolonged healing time, and periodic irrigation of the cavity. Although dentigerous cyst is considered a benign lesion, its epithelial lining has the potential to undergo neoplastic change and development of squamous cell carcinoma.
Combined marsupialization and enucleation was done to reduce morbidity, accelerated healing, development of a thickened cyst lining which makes enucleation easier and allows histopathological examination of residual tissue.
In the present case, due to patient age, size of the cyst, unfavorable position of the tooth, we can perform marsupialization followed by enucleation along with the extraction of impacted canine so as to prevent recurrence.
| Conclusion|| |
The most important features of the case among the others are the age of the patient, extent of the lesion, the provision of adequate bone regeneration without the use of any graft material, and also no nerve injury was seen after the operation. The case highlights the advantage of marsupialization followed by enucleation intraorally along with extraction of impacted canine and also the importance of performing a biopsy to define the histological type of the lesion in the management protocol of odontogenic cyst.
| References|| |
|1.||Aydin U, Yilmaz HH, Yildirim D. Incidence of canine impaction and transmigration in a patient population. Dentomaxillofac Radiol 2004;33:164-9. |
|2.||Baykul T, Saglam AA, Aydin U, Basak K. Incidence of cystic changes in radiographically normal impacted lower third molar follicles. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:542-5. |
|3.||Larheim TA, Westesson P. Maxilloficial Imaging. NewYork: Springer Verlag; 2008. ISBN: 3540786856. |
|4.||Dunfee BL, Sakai O, Pistey R, Gohel A. Radiologic and pathologic characteristics of benign and malignant lesions of the mandible. Radiographics 2006;26:1751-68. |
|5.||Som PM, Curtin HD, Silvers AR. A re-evaluation of imaging criteria to assess aggressive masticator space tumors. Head Neck 1997;19:335-41. |
|6.||Murakami A, Kawabata K, Suzuki A, Murakami S, Ooshima T. Eruption of an impacted second premolar after marsupialization of a large dentigerous cyst: Case report. Pediatr Dent 1995;17:372-4. |
|7.||Ziccardi VB, Eggleston TI, Schneider RE. Using fenestration technique to treat a large dentigerous cyst. J Am Dent Assoc 1997;128:201-5. |
|8.||Scholl RJ, Kellett HM, Neumann DP, Lurie AG. Cysts and cystic lesions of the mandible: Clinical and radiologic-histopathologic review. Radiographics 1999;19:1107-24. |
|9.||Weber AL. Imaging of cysts and odontogenic tumors of the jaw. Definition and classification. Radiol Clin North Am 1993;31:101-20. |
|10.||Bodner L, Woldenberg Y, Bar-Ziv J. Radiographic features of large cystic lesions of the jaws in children. Pediatr Radiol 2003;33:3-6. |
|11.||Chu FC, Li TK, Lui VK, Newsome PR, Chow RL, Cheung LK. Prevalence of impacted teeth and associated pathologies - A radiographic study of the Hong Kong Chinese population. Hong Kong Med J 2003;9:158-63. |
|12.||Ertas U, Yavuz MS. Interesting eruption of 4 teeth associated with a large dentigerous cyst in mandible by only marsupialization. J Oral Maxillofac Surg 2003;61:728-30. |
|13.||Grover PS, Lorton L. The incidence of unerupted permanent teeth and related clinical cases. Oral Surg Oral Med Oral Pathol 1985;59:420-5. |
|14.||Güven O, Keskin A, Akal UK. The incidence of cysts and tumors around impacted third molars. Int J Oral Maxillofac Surg 2000;29:131-5. |
|15.||Mihailova H, Nikolob V, Slavkov S. Diagnostic imaging of dentigerous cyst of the mandible. J IMAB 2008;8:8-10. |
|16.||Tümer C, Eset AE, Atabek A. Ectopic impacted mandibular third molar in the subcondylar region associated with a dentigerous cyst: A case report. Quintessence Int 2002;33:231-3. |
|17.||Ko KS, Dover DG, Jordan RC. Bilateral dentigerous cysts - Report of an unusual case and review of the literature. J Can Dent Assoc 1999;65:49-51. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]