Using fenestration technique to treat a large dentigerous cyst VB Ziccardi, TI Eggleston and RE Schneider J Am Dent Assoc 1997;128;201-205 The

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U
TO TREAT
A

LARGE DENTIGEROUS CYST

pansion of the right mandible. The boy's mother mentioned the enlargement to her son's pediatrician during a well-child visit shortly after she had noticed it. The physician prescribed an antibiotic regimen and referred the child to an oral and maxillofacial surgeon when the lesion did not diminish in size after two weeks. Clinical examination revealed an expansion in the right mandibular vestibule covered by healthy-appearing and freely movable mucosa that extended from the permanent first molar to the ipsilateral deciduous lateral incisor (Figure 1). The patient reported no pain during palpation, and the oral and maxillofacial surgeon did not note any neurosensory deficits. The expansion was firm, although some crepitus was detected when the surgeon palpated over the height of the swelling. Radiographic studies detected a large unilocular lesion with involvement of the developing bicuspids and canine (Figure 2). An occlusal radiograph showed
JADA, Vol. 128, February 1997 201

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VINCENT B. ZICCARDI, D.D.S., M.D.; TODD 1. EGGLESTON, D.D.S.; RONALD E. SCHNEIDER, D.D.S.

0he dentigerous cyst is the second most common type of odontogenic cyst found, after the radicular cyst. Clinically, it is often asymptomatic; it is discovered as an incidental radiographic finding or when acute inflammation or infection develops.1 It can, however, become extremely large and is sometimes associated with cortical expansion and erosion.2 The dentigerous cyst is always associated with an unerupted or developing tooth, and is found most frequently around the crowns of mandibular third molars, followed by maxillary canines and then maxillary third molars. It has even been reported, albeit rarely, in association with impacted deciduous teeth.3 Male patients are slightly more likely to develop dentigerous cysts than are female patients.3 Development of dentigerous cysts in animals also has been well-documented.4
This article describes use of fenestration technique to treat a large and expansile dentigerous cyst in an adolescent boy.

Dentigerous cysts are commonly

encountered In the practice of

dentistry and oral and maxillofacial surgery. Treatment modalities 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 permanent tooth buds in the management of a large dentigerous cyst
can be devastating. This article

describes the technique of fen-

estration, which removes this

entity and preserves the developing dentition.

CASE REPORT

A 8-year-old boy was referred to an oral and maxillofacial surgery clinic for consultation regarding an asymptomatic ex-

-CLINICAL PHACTICE

,ML
b,

"W

4f

Figure 1. Initial firm enlargement in right mandibular vestibule of an 8-year-old boy with normal-appearing mucosa.

Figure 2. Initial panoramic radiograph revealing displaced tooth buds and large unilocular radiolucency.

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Figure 3. Occlusal radiograph revealing buccal cortical expansion with intact lingual cortex.

Figure 4. Extraction sites of deciduous molars extended into the cystic cavity.

a large radiolucency with normal lingual cortex (Figure 3) and a thin, expanded buccal cortex. The cystic structure appeared to originate from the first bicuspid with distal and inferior displacement of the second bicuspid. A clinical diagnosis of a dentigerous cyst was made at this time. Several treatment options existed, including - removal of the cyst via enucleation; - marsupialization of the cyst to the oral mucosa, with placement of a wire to allow for drainage and decompression of the cyst;
202 JADA, Vol. 128, February 1997

- decompression of the cyst via fenestration. Enucleation carries with it a risk that the developing tooth buds could be lost, which would necessitate reimplantation. The risk of injuring or losing the tooth buds was deemed too significant for removal of the cyst via enucleation. Fenestration would allow for decompression of the cyst with preservation of the developing dentition. In addition, time would allow for continuous root development and some bone fill as the decompression evolved. Finally, the fenestration technique allows for guided eruption of the develop-

ing teeth as the overlying cystic structure is decompressed. With the patient under the influence of general anesthesia, the surgeon inserted a largegauge needle and aspirated approximately 5 cubic centimeters of a straw-colored fluid from the swelling. Cholesterol crystals were suspended in the sample, and a small amount of blood tinged the specimen at the end of the aspiration. An incision was made along the gingival crevice, and a fullthickness mucoperiosteal flap was gently elevated off the expansion in a subperiosteal plane, maintaining the bony

CLINICAL PRACTICE
cortex. The surgeon extracted the deciduous molars, which were mobile, and enlarged the socket site to form a bony window (Figure 4). Creation of the window allowed the surgeon to see a very thick and fibrous-appearing cyst wall, the visible portion of which was excised and submitted for pathological identification. Care was taken to avoid disturbing the developing tooth buds. Into this bony window, the surgeon inserted a section of intravenous tubing that had been heated and flattened on each end (Figure 5). Placement of the tube was secured with silk ligatures (Figure 6). The wound then was closed, and after surgery, the patient was instructed to irrigate the cystic space through this fenestration tube at least twice each day with sterile saline. Histologic diagnosis confirmed that the lesion was a dentigerous cyst. One month after the surgery, an impression was made of the area and a space maintainer was cemented between the permanent first molar and the deciduous canine. Radiographs taken eight months after surgery indicated continued root formation and eruption of the developing permanent dentition with apparent bone fill taking place beneath the developing teeth (Figure 7). At this examination, the dentist noted that the deciduous canine was fairly mobile and that if this tooth exfoliated, space maintenance would require a lingual arch device, which would be more complex than the method that was being used. To avoid this complication, a second surgery was performed to expose the bicuspid teeth, therefore aiding in their

eruption. Ten months after the initial surgery, eruption of the first bicuspid could be seen on a radiograph (Figure 8).
DISCUSSION

Dentigerous cysts develop from an accumulation of fluid between remnants of the enamel organ and the dental crown. The expansion is related to an increase in the osmolality resulting from passage of inflammatory cells and desquamated epithelial cells into the cystic lumen. (Pericoronal radiolucencies that exceed 2.5 to 3.0 millimeters are considered to be cystic.)

Figure 5. Intravenous tubing fashioned into a drain by heating and flattening the ends.

Since dentigerous

cysts oAtn are asympomatc, the poenial

exists

for the sur-

rounding stmctures to

suffer damage befo-e

the cyst is detected.

An intrafollicular spread of periapical inflammation from a deciduous tooth also may result in the development of a dentigerous cyst. These cysts can be referred to as inflammatory dentigerous cysts.5 Dentigerous cysts have the potential to resorb and expand into the surrounding tissue and displace bone and tooth roots as well as cause tooth displacement, malocclusion or facial asymmetry. In general, however, most dentigerous cysts are painless and are found as incidental radiographic findings.6 The controversy surrounding removal of impacted teeth, especially third molars, is in part based on the risk that a dentigerous cyst could develop.

Some authors argue that the expense of treating and potential morbidity of these lesions exceeds the benefit of prophylactic tooth removal when a patient is young and healthy.78 The development of these cysts may take years; therefore, more precise markers of potential cystic development need to be elicited before absolute advocation for the removal of all asymptomatic impacted teeth can be made.78 Since dentigerous cysts often are asymptomatic, the potential exists for the surrounding structures to suffer damage before the cyst is detected. Some complications of dentigerous cysts that have gone undetected include secondary infection with destruction of adjacent structures or metaplastic change of the cyst to a more aggressive lesion, including a malignant one.9 The epithelial cells lining the lumen of dentigerous cysts are able to undergo metaplastic change to other epithelial cell types. The cyst's lining may contain areas of orthokeratinization, ciliated cells or mucin-secreting cells. Because of this inherent ability for metaplastic change, some dentigerJADA, Vol. 128, February 1997 203

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

E a1 c mUonEEs rigure ff. E-anoramic EauLograpE eiUg after surgery with evidence of bony fill apical to tooth no. 28.

tive tissue interface. The inflamed dentigerous cyst has a denser connective tissue layer with a both premchronic inflammatory cell infiltrate. The epithelial lining of the inflamed cyst Figure 8. Radiograph taKen 1o monthis after the eximay become tial surgery showing the eruption of k booth premolars hyperplastic and development of apical bony fill. with the formation of rete ous cysts appear to progress to ridges and a keratinized surface. Mucous cells, sebaceous more aggressive lesions such as cells and ciliated epithelial cells an odontogenic keratocyst, also may be present in this cyst. ameloblastoma, mucoepiderThese elements represent the moid carcinoma or squamous cell carcinoma.10 multipotentiality of the epithelial lining of dentigerous cysts, The histopathologic findings which must be examined microof dentigerous cysts vary deon whether the is pending cyst scopically to rule out metaplastic or neoplastic changes.11 inflamed. In the noninflamed Various imaging techniques variant, the fibrous connective can indicate whether dentigertissue wall is loosely arranged ous cysts have caused bone with small islands of inactive odontogenic epithelial rests. changes. The anatomy and relaThe epithelial lining consists of tionship of the dental apexes with the adjacent bone can be a few layers of cuboidal stratified squamous epithelium with evaluated with intraoral dental a flat epithelial tissue-connecviews. Maxillary and mandibu204 JADA, Vol. 128, February 1997

lar occlusal views also can delineate the entire respective arch and reveal any buccal or lingual expansion. Panoramic radiographs are a useful first line film in that they provide a survey of the entire mandible and a portion of the maxilla. Nonintraoral radiographs provide a good view of the ramus, angle and body of the mandible. Posteroanterior and oblique views are useful in this regard. In select cases, computed tomography, or CT, is a helpful modality, especially for assessments of large lesions. Axial sections can demonstrate buccal and lingual surfaces and can define areas of expansion and erosion. Coronal sections are useful in demonstrating lesions of the maxilla and palate. The CT examination should include both bony- and soft-tissue windows. Magnetic resonance imaging, or MRI, has limited application for most mandibular lesions. It may, however, provide information on the charater of fluid within a cyst-for example, keratin, blood or the presence of solid forms.12 Surgical treatment of dentigerous cysts usually includes enucleation with removal

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CLINICAL PRACIICE
of the causative impacted tooth. An alternative treatment is marsupialization, which requires the surgeon to make an opening at the lowest point of the cystic cavity. Marsupialization is hard to rely on when treating a dentigerous cyst because it is difficult to maintain patency in a bony lesion. Also, a lateral window could drive the developing permanent dentition toward ectopic eruption, resulting in malocclusion and creating a potential need for further interceptive orthodontics. An opening along the crest, as used in the described case, would drive the permanent teeth toward their correct eruption paths.'3 The technique of fenestration was used in this case to aid in the correct development and eruption of the permanent dentition. A drain fashioned from IV tubing is easily placed into the cystic cavity from which a specimen has been removed for histologic identification. This drain is readily secured with silk ligatures, can be easily cleaned and allows a distinct port through which the patient can irrigate the cystic cavity daily. In addition, the drain is just visible radiographically so that its position relative to the erupting teeth can be followed, and the drain can be removed
or repositioned should it encroach on the erupting dentition. In this case, a simple space maintainer allowed the appropriate space for the eruption of the bicuspid teeth. The fenestration technique, as described here, simplified the surgical treatment of the cyst and offered the greatest chance for maintaining the developing dentition. The only caution is that a second minor procedure may be required to remove any residual cystic matter or to uncover emerging teeth to accelerate their eruption.
CONCLUSION Dr. Eggleston is a senior resident, Mount Sinai School of Medicine, Department of Oral and Maxillofacial Surgery, Elmhurst Hospital Center, Elmhurst, N.Y. Dr. Schneider is an assistant professor, Mount Sinai School of Medicine, Department of Oral and Maxillofacial Surgery, Elmhurst Hospital Center, Elmhurst, N.Y. 1. Bux P, Lisco V. Ectopic third molar associated with a dentigerous cyst in the subcondylar region: report of a case. J Oral Maxillofac Surg 1994;52:630-2. 2. Daley TD, Wysocki GP. The small dentigerous cyst. A diagnostic dilemma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79(1):77-81. 3. Boyczuk MP, Berger JR. Identifying a deciduous dentigerous cyst. JADA 1995; 126:643-4. 4. Gardner DG. Dentigerous cyst in animals. Oral Surg Oral Med Oral Pathol 1993;75:348-52. 5. Murakami A, Kawabata K, Suzuki A, et al. Eruption of an impacted second premolar after marsupialization of a large dentigerous cyst: case report. Pediatr Dent 1995;17:372-4. 6. Miller CS, Bean LR. Pericoronal radiolucencies with and without radiopacities. Dent Clin North Am 1994;38(1):51-61. 7. Girod SC, Gerlach KL, Kreuger G. Cysts associated with long-standing impacted third molars. Int J Oral Maxillofac Surg 1993; 22(2):110-2. 8. Carl W, Goldfarb G, Finley R. Impacted teeth: prophylactic extractions or not? N Y State Dent J 1995;61(1):32-5. 9. Falcone F, Lazow SK, Berger JR, Gold BD. Superior orbital fissure syndrome secondary to infected dentigerous cyst of the maxillary sinus. N Y State Dent J 1994;60(9):62-4. 10. Johnson LM, Sapp JP, McIntire DN. Squamous cell carcinoma arising in a dentigerous cyst. J Oral Maxillofac Surg 1994;52:987-90. 11. Waldron CA. Odontogenic cysts and tumors. In: Neville BW, Damm DD, Allen CM, Bouquot JE, eds. Oral and maxillofacial pathology. Philadelphia: Saunders; 1995:493-6. 12. Weber AL. Imaging of cysts and odontogenic tumors of the jaw. Definition and classification. Radiol Clin North Am 1993;31(1):101-20. 13. Clauser C, Zuccati GK, Barone R, Villano A. Simplified surgical-orthodontic treatment of a dentigerous cyst. J Clin Orthod 1994;28(2):103-6.

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This case report illustrates a simplified surgical treatment for a large dentigerous cyst in an adolescent in the mixed dentition stage. The procedure can be performed in the office and provides the best chance to preserve and maintain the developing dentition for eruption into a normal occlusion. The technique, however, does require close observation on the part of both the patient and treating doctor. The result can be elimination of the pathology and maintenance of dentition with minimal surgical intervention. .
Dr. Ziccardi is an assistant professor, Mount Sinai School of Medicine, Department of Oral and Maxillofacial Surgery, Elmhurst Hospital Center, Building H2-82, 79-01 Broadway, Elmhurst, N.Y. 11373. Address reprint requests to Dr. Ziccardi.

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