|Year : 2012 | Volume
| Issue : 1 | Page : 53-56
Extraoral enucleation of dentigerous cyst: A case report of rare treatment option and review of literatures
Amit Bali1, Deepika Bali2, Ashutosh Sharma1, Nageshwar Iyer1
1 Department of Oral and Maxillofacial Surgery, M. M. College of Dental Sciences and Research, Mullana, India
2 Department of Periodontics, DAV (C) Dental College, Yamuna Nagar, India
|Date of Web Publication||27-Sep-2012|
Department of Oral and Maxillofacial Surgery, M.M. College of Dental Sciences and Research, Mullana,Ambala, Haryana
Source of Support: None, Conflict of Interest: None
A dentigerous cyst is the second most common odontogenic cyst after the redicular cyst. It is most commonly associated with impacted mandibular third molar. Most common treatment for dentigerous cyst is intraoral enucleation; however, extraoral removal is required in rare cases. Here we are reporting a case of dentigerous cyst associated with an impacted mandibular third molar that required an extraoral approach for enucleation and reviewing the different rare treatment options for the dentigerous cyst.
Keywords: Dentigerous cyst, extraoral removal, review
|How to cite this article:|
Bali A, Bali D, Sharma A, Iyer N. Extraoral enucleation of dentigerous cyst: A case report of rare treatment option and review of literatures. Indian J Oral Sci 2012;3:53-6
|How to cite this URL:|
Bali A, Bali D, Sharma A, Iyer N. Extraoral enucleation of dentigerous cyst: A case report of rare treatment option and review of literatures. Indian J Oral Sci [serial online] 2012 [cited 2017 May 25];3:53-6. Available from: http://www.indjos.com/text.asp?2012/3/1/53/101679
| Introduction|| |
Dentigerous cyst is the second most common cyst of the jaw comprising 14-20% of all the jaw cysts.  It is developed by the enlargement of the follicular space that encloses the whole or part of the crown of an unerupted tooth. It occurs more frequently in males and is more commonly present in the mandible. Typically, it is associated with an impacted tooth, usually the third molar. A dentigerous cyst is usually asymptomatic, and most of the time diagnosed on routine radiographic examination. As the cyst enlarges, it causes symptoms like bone expansion, facial disfigurement, and pathological migration of teeth. A dentigerous cyst is always radiolucent and usually unilocular; however large lesion sometimes shows multilocular pattern.  The diagnosis of dentigerous cyst should not be made on radiographic evidence only; it must be based on both macroscopic and microscopic examination.
The exact histopathogenesis of dentigerous cyst is still unknown; however most of the authors support a developmental origin from tooth follicle. A prerequisite for the development of dentigerous cyst is an impacted tooth. The relative risk for a dentigerous cyst development in an impacted tooth varies considerably. In mandibular third molar, the frequency of impaction is almost same as the frequency of dentigerous cyst formation; however maxillary third molar has a much higher frequency of impaction than the cyst involvement. Similarly, the risk of dentigerous cyst formation in relation to mandibular first premolar, maxillary incisors, and mandibular second premolar is very high, but the frequency of failure of eruption of these teeth are extremely low. ,
Dentigerous cyst occasionally becomes extensive since lesion is asymptomatic initially and achieves considerable size before being diagnosed.  In such conditions, treatment becomes more difficult as the involved tooth is impacted and displaced to a considerable distance due to cystic pressure. Surgery may require removal of several teeth or tooth buds or may endanger the vitality of adjacent teeth. In spite of several damaging sequels, dentigerous cyst must be surgically removed. Dentigerous cyst is usually removed through an intraoral approach; however on rare occasion an extraoral approach is required. Here, we are reporting a case of dentigerous cyst which was enucleated by extraoral approach.
| Review of Literature|| |
There are two basic surgical procedures for the treatment of dentigerous cyst: marsupialization and enucleation. Both of these surgical procedures are done by intraoral approach, but in rare cases it requires extraoral approach. In this article, we are reviewing the rare treatment options available for dentigerous cyst.
Sheldon Mintz et al,  had reported an extraoral removal of dentigerous cyst in two cases. According to them extraoral removal provides better surgical access, removal of tooth with minimal bone loss, and rigid fixation plate placement with ease, if required.
M. Cemil Buyukkurt et al,  presented a case in which an extraoral removal of dentigerous cyst associated with impacted transmigrant mandibular canine was done. They also supported that extraoral removal of dentigerous cyst provides better accessibility and less bone removal for tooth removal.
Boi JR et al,  had treated a dentigerous cyst in a 6-year-old child with the help of erbium laser. The cyst was treated by mucous fenestration, drainage of the fluid content, and curettage of the bone cavity. Bone regeneration, repositioning of displaced tooth bud, and correct eruption of affected tooth occurred postoperatively in 5 months.
Nishide N et al,  had used irrigational therapy to treat a dentigerous cyst in a 72-year-old man who was not willing for surgery because he had no symptoms associated with the cyst, and he had other medical complications. After one year of therapy, remarkable bone regeneration was observed. They concluded that irrigational therapy appears to be an effective, less-invasive alternative to surgery for geriatric patients.
| Case Report|| |
A 58-year-old woman reported to the Department of Oral and Maxillofacial Surgery of M.M. College of Dental Sciences and Research Mullana, Ambala, Haryana, India, with chief complaint of slight pain and pus discharge intraorally for the last 2 months. Her prior medical history was not significant and she did not give any history of trauma to the mandible. Her intraoral examination revealed mild extraoral swelling on right angle region of the mandible. Intraoral pus discharge was present in relation to the right mandibular third molar. Clinically third molar was missing, but buccal cortical plate expansion was present. Her occlusion was stable in class 1 relationship. Interincisal opening was 38 mm and there was full range of mandibular movements. She had maintained a good oral hygiene. Panoramic radiograph evaluation revealed a large well-defined unilocular radiolucency surrounding the crown of right mandibular third molar [Figure 1]. Tooth was displaced almost to the lower border of the mandible.
|Figure 1: Panoramic radiograph showing impaction of right mandibular third molar surrounded by radiolucent lesion.|
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Differential diagnosis included odontogenic cysts, odontogenic tumor, or nonodontogenic lesion. The incisional biopsy of the lesion was done. Histopathological examination confirmed the diagnosis of dentigerous cyst. After establishing the diagnosis, intraoral verses extraoral approach and their complications for enucleation of this lesion was reviewed. Finally the decision for extraoral enucleation was taken because intraoral procedure in this case would lead to excessive removal of bone, higher chances of mandible fracture, and limited accessibility.
The patient underwent surgery in general anesthesia. Risdon incision was made in right submandibular region through the skin and subcutaneous tissue. Layer-wise dissection was done through the platysma and deep fascia up to the lower border of mandible and facial vessels were ligated. At the level of the lower border, pterygomasseteric sling was incised and masseter muscle attachment was stripped off. Once masseter muscle was retracted, lateral expansion of the buccal cortical plate was apparent. Circumferential bone trough was created conservatively and tooth was removed after sectioning [Figure 2] and [Figure 3]. Enucleation and curettage was performed in the region of lesion [Figure 4]. After examining the thickness of lower border of the mandible, it was decided not to plate the area. Layer-wise suturing was done after achieving the hemostasis. Specimen was sent for histopathological examination. Postoperative course of the patient was uneventful. Postoperative radiograph showed complete removal of the cyst with tooth and intact lower border of the mandible [Figure 5].
|Figure 4: Showing surgical site after extraoral eneucleation of dentigerous cyst.|
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The histopathological examination reported a cystic structure lined by a thin layer of focally inflamed odontogenic epithelium. The fibrous connective tissue contained chronic inflammatory cells predominantly plasma cells along with lymphocytes and few scattered acute inflammatory cells [Figure 6]. The final diagnosis was infected dentigerous cyst.
|Figure 6: Showing histological section of dentigerous cyst (hematoxylin and eosin staining, original magnification ×10).|
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| Discussion|| |
Dentigerous cyst most commonly occurs in people between 10-30 years of age.  In this case the age of the patient is 58 years; dentigerous cyst at this age is not very common. Dentigerous cyst is the second most common odontogenic cyst in adults and accounts for half of those in children and adolescents.  It is estimated that 1% of the impacted teeth develops dentigerous cyst.  It is mainly associated with mandibular third molar. Maxillary canine, maxillary third molar, and mandibular premolar are involved in the decreasing order of frequency.  Dentigerous cyst is usually diagnosed on routine dental examination because most of the time it is asymptomatic, although these cysts can enlarge and cause bone expansion, tooth displacement, and even pathological fracture. Dentigerous cysts become painful if secondarily infected. Radiographically, dentigerous cyst is a well-defined unilocular radiolucency surrounding the crown of an impacted tooth. These cysts can be classified as central, lateral, and circumferential. 
Dentigerous cysts developed by accumulation of fluid either between reduced enamel epithelium and enamel or in-between the layers of the enamel organ. According to Main, such fluid accumulation occurs as a result of pressure exerted by the erupting tooth on the follicle that obstructs the venous outflow and hence induce rapid transudation of serum across the capillary wall.  However, according to Toller, dentigerous cyst arises by the breakdown of the proliferating cells of the follicle after impeded eruption. These breakdown products increase the osmotic pressure, hence results in cyst formation.  Angela Benn et al suggested the role of inflammation in the first and early second decade of life. 
Histologically, dentigerous cyst may or may not show inflammation. It usually shows a thin fibrous cyst wall consisting of young fibroblast separated by stroma and ground substance. Epithelial lining consists of 2-4 layers of flat or cuboidal cells. Characteristically, epithelial lining is not keratinized. According to Toller, discontinuity in the epithelial lining may be seen in the presence of intense inflammatory infiltrate. 
The diagnosis of dentigerous cyst is based on the combination of radiographic, histopathological, and clinical features. The usual treatment is careful enucleation of cyst together with the removal of unerupted tooth. If eruption of the involved tooth is feasible then the marsupialisation is performed. Large dentigerous cysts can be treated with enucleation or marsupialisation with complete lining may be excised at a later stage with less extensive surgical procedure. 
Dentigerous cyst is usually removed by an intraoral approach; however on rare occasion an extraoral approach is required for these lesions.  In this case, impacted mandibular third molar lies at the lower border of the mandible and because of the old age of the patient there was no need to save the tooth. Intraoral enucleation along with the tooth removal requires excessive removal of the bone, which can increase the chances of mandibular fracture. Extraoral approach for this lesion provided the better access for the enucleation and internal plate fixation if fracture would have occurred intraoperatively. The major disadvantage of extraoral approach is scar formation and possible facial nerve involvement.  In this case, incision was given 2 cm below the lower border of the mandible to save the facial nerve.  No prominent scar formation occurred because of proper layer-wise closure of the wound in this case. In intraoral approach, one can avoid extra oral scar and injury to the facial nerve; however intraoral approach in this case provided limited access, excessive bone removal, and increased chance of inferior alveolar nerve injury. Thus in these type of cases where the location of the tooth is such that intraoral approach limits the accessibility and excessive bone removal is required for enucleation of the cyst along with the tooth removal, an extraoral approach provides an appropriate treatment option.
| References|| |
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|2.||Main DM. The enlargement of epithelial jaw cysts. Odontol Revy 1970;21:29-49. |
|3.||Toller PA. Origin and growth of cysts of the jaws. Ann R Coll Surg Engl 1967;40:306-36. |
|4.||Benn A, Altini M. Dentigerous cyst of inflammatory origin- A clincopathological study. Oral Surg Oral Pathol Oral Radiol Endo 1996;81:203-9. |
|5.||Mintz S, Allard M, Nour R. Extraoral Removal of Mandibular Odontogenic Dentigerous cysts- a Report of 2 Cases. J Oral Maxillofac Surg 2001;59:1094-6. |
|6.||Buyukkurt MC, Aras MH, Caglaroglu M. Extraoral removal of a transmigrant mandibular canine associated with a detigerous cyst. Quintessence Int 2008;39:767-70. |
|7.||Boi JR, Poirier C, Hernandez M, Espasa E. Laser - assisted treatment of a dentigerous cyst- case report. Pediatr Dent 2007;29:521-4. |
|8.||Nishide N, Hitomi G, Miyoshi N. Irrigation therapy of dentigerous cyst in a geriatric patient - a case report. Spec Care Dentist 2003;23:70-2. |
|9.||Aziz SR, Pulse C, Dourmas MA, Roser SM. Inferior alveolar nerve paresthesia associated with mandibular dentigerous cyst. J Oral Maxillofac Surg 2002;60:457-9. |
|10.||Bhatia SK, Collard M, Divcic D, Hunter L. Inverted impaction of a mandibular premolar associated with dentigerous cyst - report of a case. Dent Update 2009;36:374-6. |
|11.||Shafer WG, Hine MK, Levy BM. Shafer's textbook of Oral Pathology. 6 th ed. Amsterdam: Elsevier; 2009. p. 254-8. |
|12.||Ellis E, Zide MF. General Principles For Approaches To The Facial Skeleton. 2 nd ed. New York: LippinCott, Williams and Wilkins, 2006. p. 123-38. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]