ORTHO 170 1-13 Ó 2015 CEO Published by / E´dite´ par Elsevier Masson SAS All rights reserved / Tous droits re´serve´s
Original article Article original
Recovering teeth from a large dentigerous cyst: A case report cupe ration de dents associe es a` un kyste Re re important : e tude de cas dentige Ivano MALTONIa, Giorgia SANTUCCIb, Manuela MALTONIb, Lucia ZOLIb, Alessandro PERRIc, Antonio GRACCOd,* a
Department of Orthodontics, University of Ferrara, via Montebello 31, 44100 Ferrara, Italy Via Oriani 1, 47122 Forlı`, Italy c Via Feri 1, 35126 Padova, Italy d Department of Neuroscience, University of Padova, via Venezia 90, 35100 Padova, Italy b
Available online: XXX / Disponible en ligne : XXX
Summary
sume Re
A dentigerous cyst is an odontogenic lesion caused by the expansion of the follicle surrounding the crown of impacted, embedded or unerupted teeth. These cysts may cause destruction of the bone, displacement of adjacent teeth, resorption of their roots and prevent the eruption of cyst-associated permanent teeth. This paper discusses successful use of marsupialization combined with orthodontic treatment to treat cyst-associated impacted permanent teeth and to correct a class II open bite malocclusion. Ó 2015 CEO. Published by Elsevier Masson SAS. All rights reserved
est une lesion Un kyste dentigere odontogenique qui est for par la dilatation du follicule entourant la couronne de mee ou non evolu dents incluses, enclavees ees. Ces kystes peu vent provoquer une destruction osseuse, le deplacement des ^ dents voisines et la resorption de leurs racines. Ils empechent au egalement l’eruption des dents permanentes associees kyste. Cet article presente l’utilisation de la marsupialisation avec un traitement orthodontique pour permettre le combinee et pour corriger traitement de dents permanentes enclavees une malocclusion de classe II avec beance. Ó 2015 CEO. E´dite´ par Elsevier Masson SAS. Tous droits re´serve´s
Key-words
s Mots-cle
·· ·
Dentigerous cyst. Marsupialization. Impacted teeth.
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re. Kyste dentige Marsupialisation. Dents incluses.
Correspondence and reprints / Correspondance et tires a` part. e-mail address / Adresse e-mail : [email protected] (Antonio Gracco) *
International Orthodontics 2015 ; X : 1-13 http://dx.doi.org/10.1016/j.ortho.2015.03.013
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Introduction
Introduction
Dentigerous cyst is one of the most common lesions of the jaws [1]. It is an odontogenic lesion originating with the expansion of the follicle surrounding the crown of impacted, embedded or unerupted teeth [2]. Expansion of the dental follicle is caused by accumulating fluid between the tooth crown and the reduced enamel epithelium. The enlargement of the cyst is progressive and generally painless. This type of cyst evolves slowly and may be present for several years before being noticed. It may result in destruction of bone, displacement of adjacent teeth and resorption of their roots and may prevent eruption of cyst-associated permanent teeth [3–5]. Surgical enucleation of the dentigerous cyst combined with extraction of the cyst-associated impacted or unerupted tooth is the standard treatment but it is not always the best choice in young patients [6,7]. Marsupialization offers an alternative conservative treatment because it is less invasive, preserves the tooth and provides potential for the tooth to erupt into the oral cavity, provided space is available [8,9]. After marsupialization, orthodontic traction of the impacted tooth is often performed to bring the cyst-associated tooth or an ectopic tooth into the dental arch [10,11].
re repre sente l’une des le sions de la ma ^choire Le kyste dentige pandues [1]. Il s’agit d’une le sion forme e par les plus re l’expansion du sac folliculaire entourant les couronnes de es ou non e volue es [2]. La croissance dents incluses, enclave e par l’accumulation de fluide entre la du follicule est provoque pithe lium ame laire re duit. couronne dentaire et l’e ne ralement L’agrandissement du kyste est progressif et ge volution de ces kystes est lente et peut durer indolore. L’e es sans e ^tre remarque e. Elle peut donner lieu plusieurs anne placement a` une destruction de la substance osseuse, a` un de sorption de leurs racines et des dents avoisinantes et a` la re ^cher l’e ruption des dents permanentes associe es peut empe thode de traitement standard consiste en au kyste [3–5]. La me nucle ation du kyste dentige re combine e a` l’extraction de la l’e volue e associe e au kyste. Cependant, ce dent incluse ou non e pour les jeunes traitement n’est pas toujours recommande patients [6,7]. La marsupialisation offre un traitement alternatif conservateur qui est moins invasif, conserve la dent et potenmergence dans la cavite buccale si on dispose de tialise son e s la marsupialisation, on suffisamment d’espace [8,9]. Apre de souvent a` une traction orthodontique de la dent proce e au kyste ou une dent incluse pour amener la dent associe ectopique sur l’arcade dentaire [10,11].
Case history
Etude de cas
A 15-year-old boy was referred for treatment for late maxillary teeth exfoliation. Intraoral clinical examination of the upper arch revealed the persistence, on the right, of the deciduous canine and the second deciduous molar and, on the left side, just the deciduous canine. A painless, hard swelling was localized in the right posterior maxillary buccal region (fig. 1). Panoramic X-ray revealed the presence of a large translucent, uniloculated area with well-defined margins on the maxillary right side containing the unerupted maxillary canine, and first and second bicuspids. On the left side, the maxillary canine was impacted (fig. 2). Computerized axial tomography showed more precisely the lesion that had virtually reduced the right maxillary sinus to a gaping hole (fig. 3). Lateral radiographic examination and cephalometric tracing revealed a skeletal class II open bite malocclusion (fig. 4, Table I).
te adresse pour traitement en Un gar¸con de 15 ans nous a e raison d’un retard d’exfoliation d’une dent maxillaire. L’examen ve le la persistance, clinique intraoral de l’arcade maxillaire re me molaire de lait a` droite, de la canine de lait et de la deuxie ^ te gauche, on n’observe que la canine de lait. alors que, du co faction dure et douloureuse est situe e poste rieureUne tume ^ te vestibulaire maxillaire droit (fig. 1). Le panorament du co ve le la pre sence d’une importante zone radioclaire mique re finies du co ^ te maxillaire unilobulaire avec des limites bien de volue e et les predroit contenant la canine maxillaire non e re et deuxie me pre molaires. Du co ^ te gauche, on note la mie canine maxillaire incluse (fig. 2). La tomographie axiale rique, plus pre cise, re ve le que la le sion a presque re duit nume ante (fig. 3). le sinus maxillaire droit a` une ouverture be ral et le trace ce phalome trique L’examen radiographique late sence d’une malocclusion squelettique de montrent la pre ance (fig. 4, Tableau I). classe II avec be
Treatment objectives
Objectifs du traitement
Our first aim was to recover the affected teeth after marsupialization of the dentigerous cyst. Another treatment option could have been to perform complete surgical enucleation of the cyst with the associated impacted maxillary teeth in order to replace them with implants. However, because of the patient’s age, this method would have entailed a significant reduction in maxillary growth and in alveolar process bone
cupe rer les dents affecte es par Notre premier objectif est de re s marsupialisation du kyste dentige re. Un autre le kyste apre a` re aliser une e nucle ation traitement possible aurait consiste te du kyste ainsi que des dents maxillaires incluses comple pour les remplacer par des implants. Cependant, en raison ^ge du patient, il se produirait alors une re duction signifide l’a s cative de la croissance maxillaire et des dimensions du proce
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International Orthodontics 2015 ; X : 1-13
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Recovering teeth from a large dentigerous cyst: A case report
cupe ration de dents associe es a` un kyste dentige re important : e tude de cas Re
[(Fig._1)TD$IG]
Fig. 1: a–i: pretreatment photographs. Fig. 1 : a–i : vues avant traitement.
dimensions before the end of growth, precluding the possibility of implant placement. Transverse maxillary growth is dependent on pneumatization of the maxillary sinus: surgical cyst enucleation would have compromised maxillary growth and drastically mutilated the permanent dentition. The second aim was to correct the dentoskeletal malocclusion. Orthodontic treatment was performed after resolution of the cyst-related problems.
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olaire avant la fin de la pe riode de croissance, interdisant alve ainsi le placement d’implants. La croissance maxillaire transe a` la pneumatisation du sinus maxillaire. versale est lie nucle ation chirurgicale du kyste compromettrait la croisL’e graderait de fa¸con drastique la densance du maxillaire et de me objectif consiste a` corriger la ture permanente. Le deuxie malocclusion dentosquelettique. Le traitement orthodontique alise apre s correction des proble mes lie s au kyste. est re
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[(Fig._2)TD$IG]
Fig. 2: Pretreatment panoramic radiograph. Fig. 2 : Panorex avant traitement.
Treatment progress
Evolution du traitement
The surgical procedures began with the extraction of the upper right side deciduous teeth (canine and second molar), reflection of a mucoperiostal flap and removal of the bone overlying the cyst (fig. 5). The “roof” of the cyst was removed and the surrounding mucoperiosteum was sutured to the margins of the cyst wall after evacuation of the contents. Tissue from the exposed membranous wall was sent to the laboratory for histologic examination, which confirmed the diagnosis of dentigerous cyst. The wound was kept irrigated and cleaned during
Les interventions chirurgicales commencent par l’extraction, ^ te droit, des dents de lait maxillaires (canine et deuxie me du co molaire) suivie de la re flexion d’un lambeau pe rioste et de pre section de l’os surplombant le kyste (fig. 5). Le « toit » du la re et le mucope rioste environnant est kyste est ensuite incise aux bords de la paroi kystique apre s drainage de ses suture e contenus. Les tissus de la paroi membraneuse expose s au laboratoire pour analyse histologique sont adresse re. La plaie est qui confirme le diagnostic de kyste dentige
Table I
Tableau I
phalome trique avant traitement. Analyse ce
Pretreatment cephalometric analysis.
Normal Skeletal / squelettique S-N-A S-N-B A-N-B S-N/ANS-PNS S-N/Go-Gn ANS-PNS / Go-Gn Dental / Dentaire U1/ANS-PNS L1/Go-Gn L1-A-Pg (mm) Overjet (mm) Overbite (mm) U1/L1
4
82 W 3.5 80 W 3.5 2 W 2.5 8 W 3.0 33 W 2.5 25 W 6.0 110 W 6.0 94 W 7.0 2 W 2.0 3.5 W 2.5 2 W 2.5 132 W 6.0
Pretreatment / Avant traitement 85 80 5 3 37 34 100 81 1 mm 3 mm 1 mm 145
International Orthodontics 2015 ; X : 1-13
ORTHO 170 1-13
Recovering teeth from a large dentigerous cyst: A case report
cupe ration de dents associe es a` un kyste dentige re important : e tude de cas Re
[(Fig._3)TD$IG]
Fig. 3: a–e: pre-operative computerized axial tomography. rique pre ope ratoire. Fig. 3 : a–e : tomographie axiale nume
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[(Fig._4)TD$IG]
Fig. 4: Pretreatment headfilm. le radiographie avant traitement. Fig. 4 : Te
three months by daily irrigations through the open surgical window. These measures relieved pressure from inside the cyst and the cavity was gradually obliterated by apposition of soft and bone tissue to close the defect [12]. Six months after marsupialization, the upper right canine and the first and second bicuspids were surgically disimpacted because they had not erupted spontaneously. The closed-flap
[(Fig._5)TD$IG]
e et nettoye e pendant trois mois avec des maintenue irrigue ^tre chirurgicale irrigations quotidiennes passant par la fene cautions diminuent la pression exerce e entrouverte. Ces pre est graduellement oblite re e par appopar le kyste et la cavite sion [12]. sition de tissus mous et osseux qui referment la le s la marsupialisation, la canine et les premie re et Six mois apre me pre molaires supe rieures droites, toujours non deuxie volue es, sont de sincluses chirurgicalement. La technique e
Fig. 5: Post-marsupialization intraoral lateral view. rale intraorale apre s marsupialisation. Fig. 5 : Vue late
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[(Fig._6)TD$IG]
Fig. 6: a, b: surgical disimpaction of upper right teeth. sinclusion chirurgicale des dents maxillaires droites. Fig. 6 : a, b : de
[(Fig._7)TD$IG]
Fig. 7: a–c: orthodontic traction of upper right teeth through the closed-flap. . Fig. 7 : a–c : traction orthodontique des dents maxillaires droites au travers du lambeau ferme
technique and subsequent orthodontic traction were used [13] (fig. 6). The erupted maxillary incisors, the upper left teeth and the right first and second molars were bonded with a Damon appliance. Brackets were bonded on the right canine and first and second bicuspids through the surgical window access and then extruded by tying the brackets directly to the .01400 CuNiTi archwire using long metal ligatures so as to cause the archwire to deflect. Restitution of the deflection force pulled the teeth with a continuous force without having to change ligatures. At the same time, space was created to allow eruption of the impacted teeth to their proper position (fig. 7). Three months after surgical dental recovery, the lower arch was bonded and, four months later, both the upper left and right canines were disimpacted (fig. 8). In this case, the flap was repositioned and sutured apically to the cementoenamel junction. During treatment, vertical elastics were used (fig. 9) and radiographic records were obtained to verify the accuracy of the orthodontic movements. After 48 months, the appliance was removed and a bonded fixed retainer was used in both arches: from canine to canine in the lower arch and from the right canine to left lateral incisor in the upper.
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suivie d’une traction orthodontique est a` lambeau ferme e [13](fig. 6). Les incisives maxillaires, les dents utilise rieures gauches et les premie re et deuxie me molaires supe rieures droites sont appareille es avec des attaches supe s a` la canine droite et aux preDamon. Les boıˆtiers sont relie re et deuxie me pre molaires au travers de la fene ^tre chirmie gresse es en attachant les urgicale. Les dents sont ensuite e boıˆtiers directement au fil .01400 CuNiTi avec de longues ligatalliques afin d’ame nager une de flection de l’arc. La tures me flection tracte les dents restitution continue de la force de de ^me temps, l’espace sans avoir a` changer les ligatures. En me e permettant l’e ruption des dents incluses a` leur place est cre sur l’arcade (fig. 7). s la re cupe ration de la chirurgie, l’arcade Trois mois apre rieure est appareille e et quatre mois plus tard, les canines infe senclave es (fig. 8). Chez maxillaires droite et gauche sont de et suture en apical de la ce patient, le lambeau est repositionne mentoame laire. jonction ce lastiques verticaux sont utilise s pendant le traitement Les e s radiographiques sont obtenus pour (fig. 9) et des cliche rifier l’exactitude des mouvements orthodontiques. ve s 48 mois, l’appareil est de pose et une contention fixe Apre e est place e aux deux arcades, de canine a` canine a` l’arcolle rieure et de la canine droite a` l’incisive late rale cade infe rieure. gauche a` la supe
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[(Fig._8)TD$IG]
Fig. 8: Disimpaction of non-cyst-associated upper left. sinclusion d’une dent maxillaire gauche non associe e au Fig. 8 : De kyste.
[(Fig._9)TD$IG]
Fig. 9: a–i: orthodontic treatment progress with vertical elastics. volution du traitement orthodontique utilisant des e lastiques verticaux. Fig. 9 : a–i : e
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cupe ration de dents associe es a` un kyste dentige re important : e tude de cas Re
[(Fig._10)TD$IG]
Fig. 10: a–h: posttreatment photographs. s traitement. Fig. 10 : a–h : vue apre
[(Fig._1)TD$IG]
Fig. 11: Posttreatment panoramic radiograph. s traitement. Fig. 11 : Panorex apre
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[(Fig._12)TD$IG]
Fig. 12: Posttreatment headfilm. le radiographie apre s traitement. Fig. 12 : Te
Table II
Tableau II
phalome trique apre s traitement. Analyse ce
Posttreatment cephalometric analysis.
Normal Skeletal / squelettique S-N-A S-N-B A-N-B S-N/ANS-PNS S-N/Go-Gn ANS-PNS/Go-Gn Dental / dentaire U1/ANS-PNS L1/Go-Gn L1-A-Pg (mm) Overjet (mm) Overbite (mm) U1/L1
10
82 W 3.5 80 W 3.5 2 W 2.5 8 W 3.0 33 W 2.5 25 W 6.0 110 W 6.0 94 W 7.0 2 W 2.0 3.5 W 2.5 2 W 2.5 132 W 6.0
traitement Postreatment / Apres
84 82 2 2 33 31 123 88 4 mm 3 mm 1 mm 117
International Orthodontics 2015 ; X : 1-13
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Recovering teeth from a large dentigerous cyst: A case report
cupe ration de dents associe es a` un kyste dentige re important : e tude de cas Re
[(Fig._13)TD$IG]
Fig. 13: a–i: follow-up photographs 14 months after end of treatment. s la fin du traitement. Fig. 13 : a–i : vues de suivi 14 mois apre
Treatment results
sultats de traitement Re
Our treatment induced physiological maxillary growth and a well-intercuspidated class I occlusion with coincident dental and facial midlines (figs. 10–12, Table II). All teeth showed normal vitality. Periodontal tissues were influenced by poor oral hygiene. The orthopantomogram showed sufficient root parallelism even though some teeth had an unusual shape. After 14 months, we were able to confirm the stability of the results (fig. 13).
la croissance physiologique du Notre traitement a stimule maxillaire et une occlusion de classe I avec une excellente dianes intercuspidation et un bon alignement des lignes me faciales et dentaires (fig. 10–12, Tableau II). Toutes les dents normale. Les tissus parodontaux ont e te affichent une vitalite s par une hygie ne buccale de ficiente. Le panorex affecte ve le un paralle lisme radiculaire suffisant me ^me si plusieurs re s 14 mois, on peut dents ont une forme inhabituelle. Apre cier la stabilite des re sultats (fig. 13). appre
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Discussion
Discussion
Dentigerous cysts are the most common type of developmental odontogenic cyst [1]. This kind of cyst occurs most frequently in the mandibular third molar or maxillary canine regions, followed by mandibular premolars, supernumerary teeth and, rarely, the central incisors [10]. Generally, dentigerous cysts are painless but may cause facial swelling and delayed tooth eruption. They may progress slowly for many years without being noticed and can give rise to destruction bone, displacement of adjacent teeth and resorption of their roots and prevent eruption of the cyst-affected permanent teeth [2–6]. The standard treatment of a dentigerous cyst is surgical removal and extraction of the cyst-associated impacted or unerupted tooth [4,7]. However, marsupialization should be considered when tooth displacement and great loss of bone have occurred. With marsupialization, formation of new bone is stimulated because of the decreased intracystic pressure and the cyst-affected teeth can erupt spontaneously into the arch, provided there is sufficient space [8,9].
res constituent le type de kyste de Les kystes dentige veloppement odontoge ne le plus fre quent [1]. Ils se produide quemment dans les re gions de la troisie me sent le plus fre molaire mandibulaire et des canines maxillaires, suivies des molaires mandibulaires, des dents surnume raires et, rarepre ne ralement, les kystes ment, des incisives centrales [10]. Ge res sont indolores mais peuvent provoquer une dentige faction faciale et un retard d’e ruption dentaire. Ils peuvent tume voluer lentement pendant de longues anne es sans e ^tre e s et donner lieu a` une destruction osseuse, un remarque placement des dents avoisinantes et une re sorption de de ^cher l’e ruption des dents perleurs racines, et peuvent empe es au kyste [2–6]. Le traitement standard manentes associe re consiste en l’ablation chirurgicale du d’un kyste dentige volue e associe e kyste et l’extraction de la dent incluse ou non e [4,7]. Cependant, il conviendrait d’envisager la marsupialisaplacement dentaire et une tion lorsqu’il s’est produit un de ^ce a` la marsupialisation, la forperte osseuse importants. Gra e en raison de la re duction de la mation de l’os est stimule es au kyste peuvent pression intrakystique et les dents associe ment trouver leur place sur l’arcade a` condition de spontane disposer d’un espace suffisant [8,9]. nient majeur de cette technique chirurgicale provient L’inconve s in situ. Me ^me si l’e chantillon des tissus pathologiques laisse au laboratoire pour analyse histologique, tissulaire est envoye siduels peuvent encore he berger une le sion plus les tissus re cet inconve nient, nous avons de cide de agressive [14]. Malgre ^ge du traiter ce cas par marsupialisation en raison du jeune a tait important et avait de ja` patient et du fait que le kyste e place trois dents permanentes. de lai de 3 mois avant de de cider d’une Nous proposons un de extraction ou d’un recours a` une traction orthodontique. Ce tre cissement du temps d’attente est critique puisque le re ruption de la dent, me ^me kyste peut, a` lui seul, promouvoir l’e tement si la racine de la dent permanente incluse est comple e [15]. forme sent, six mois apre s la marsupialisation, la Dans le cas pre me pre molaire supe rieures ont fait canine droite et la deuxie sinclusion chirurgicale en raison de leur nonl’objet d’une de ruption spontane e. Le traitement orthodontique est re serve e cupe rer, aligner et niveler les dents et pour au cas ou` il faut re peaufiner l’occlusion dans ce cas de classe II hyperdivergent.
The major disadvantage of this surgical technique is the pathologic tissue left in situ. Even if a tissue sample is sent to the laboratory for histological examination, there is still the possibility of a more aggressive lesion in the residual tissue [14]. Despite this drawback, we decided to treat this case by marsupialization because the patient was young and because the cyst was large and had caused displacement of three permanent teeth. A period of 3 months after marsupialization is suggested as essential before deciding whether to extract or use orthodontic traction. This delay is critical because cyst shrinkage can promote tooth eruption, even if the root of the permanent impacted tooth is completely formed [15]. In our case, six months after marsupialization, the upper right canine and first and second bicuspids were surgically disimpacted because they had not erupted spontaneously. Orthodontic treatment was used to correct, align and level the teeth and refine this case of class II open bite occlusion.
Conclusions
Conclusions
This paper discusses successful use of marsupialization combined with orthodontic treatment for treating cyst-associated teeth, included permanent teeth, and to resolve a class II open bite malocclusion.
sente l’utilisation re ussie de la marsupialisation Cet article pre e au traitement orthodontique pour traiter des dents associe es a` un kyste et pour re soudre une classe II incluses associe ance. avec be
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Recovering teeth from a large dentigerous cyst: A case report
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Disclosure of interest
claration d’inte re ^ts De
The authors declare that they have no conflicts of interest concerning this article.
clarent ne pas avoir de conflits d’inte re ^ ts en Les auteurs de relation avec cet article.
References/References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
Shivaprakash P, Rizwanulla T, Baweja DK, Noorani HH. Save-a-tooth: conservative surgical management of dentigerous cyst. J Indian Soc Pedod Prev Dent 2009;27:52–7. Buyukkurt MC, Omezli MM, Miloglu O. Dentigerous cyst-associated with an ectopic tooth in the maxillary sinus: a report of 3 cases and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109(1):67-71. Scott-Brown otolaryngology, 6th ed. Butterworth-Heinemann, Oxford 1997. Tournas AS, Tewfik MA, Chauvin PJ, Manoukian JJ. Multiple unilateral maxillary dentigerous cysts in a nonsyndromic patient: a case report and review of the literature. Int J Pediatr Otorhinolaryngol Extra 2006;1:100–6. Avitia S, Hamilton JS, Osborne RF. Dentigerous cyst presenting as orbital proptosis. Ear Nose Throat J 2007;86:23–4. Smith 2nd. JL, Kellman RM. Dentigerous cysts presenting as head and neck infections. Otolaryngol Head Neck Surg 2005;133:715–7. Martınez-Perez D, Varela-Morales M. Conservative treatment of dentigerous cysts in children: a report of 4 cases. J Oral Maxillofac Surg 2001;59:331–3. 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(6):728–30. Jayam C, Mitra M, Bandlapalli A, Jana B. Aggressive dentigerous cyst with ectopic central incisor. BMJ Case Rep 2014;2014:. Miyawaki S, Hyomoto M, Tsubouchi J, Kirita T, Sugimura M. Eruption speed and rate of angulation change of a cyst-associated mandibular second premolar after marsupialization of a dentigerous cyst. Am J Orthod Dentofacial Orthop 1999;116(5):578–84. Tominaga K, Kikuta T, Fukuda J, Uemura S, Yasumitsu C, Yamada N. Marsupialization for dentigerous cysts in children: especially behaviours of the involved teeth. Jpn J Oral Maxillofac Surg 1988;34:133–8. Maltoni I, Maltoni M, Siciliani G. Rescuing teeth from dentigerous cyst: a case report. Prog Orthod 2007;8(1):46-53. Gracco A, Maltoni I, Maltoni M, Zoli L. Eruption of a labially impacted canine using a closed-flap technique and orthodontic wire traction. J Clin Orthod 2012;46(10):625–30 [quiz 632]. Peterson LJ, Ellis III. E, Hupp JR, et al. Contemporary oral and maxillofacial surgery, 3rd ed. Mosby, St Louis, MO540 1998. Hyomoto M, Kawakami M, Inoue M, Kirita T. Clinical conditions for eruption of maxillary canines and mandibular premolars associated with dentigerous cysts. Am J Orthod Dentofacial Orthop 2003;124(5):515–20.
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Original article Article original
Recovering teeth from a large dentigerous cyst: A case report cupe ration de dents associe es a` un kyste Re re important : e tude de cas dentige Ivano MALTONIa, Giorgia SANTUCCIb, Manuela MALTONIb, Lucia ZOLIb, Alessandro PERRIc, Antonio GRACCOd,* a
Department of Orthodontics, University of Ferrara, via Montebello 31, 44100 Ferrara, Italy Via Oriani 1, 47122 Forlı`, Italy c Via Feri 1, 35126 Padova, Italy d Department of Neuroscience, University of Padova, via Venezia 90, 35100 Padova, Italy b
Available online: XXX / Disponible en ligne : XXX
Summary
sume Re
A dentigerous cyst is an odontogenic lesion caused by the expansion of the follicle surrounding the crown of impacted, embedded or unerupted teeth. These cysts may cause destruction of the bone, displacement of adjacent teeth, resorption of their roots and prevent the eruption of cyst-associated permanent teeth. This paper discusses successful use of marsupialization combined with orthodontic treatment to treat cyst-associated impacted permanent teeth and to correct a class II open bite malocclusion. Ó 2015 CEO. Published by Elsevier Masson SAS. All rights reserved
est une lesion Un kyste dentigere odontogenique qui est for par la dilatation du follicule entourant la couronne de mee ou non evolu dents incluses, enclavees ees. Ces kystes peu vent provoquer une destruction osseuse, le deplacement des ^ dents voisines et la resorption de leurs racines. Ils empechent au egalement l’eruption des dents permanentes associees kyste. Cet article presente l’utilisation de la marsupialisation avec un traitement orthodontique pour permettre le combinee et pour corriger traitement de dents permanentes enclavees une malocclusion de classe II avec beance. Ó 2015 CEO. E´dite´ par Elsevier Masson SAS. Tous droits re´serve´s
Key-words
s Mots-cle
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Dentigerous cyst. Marsupialization. Impacted teeth.
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re. Kyste dentige Marsupialisation. Dents incluses.
Correspondence and reprints / Correspondance et tires a` part. e-mail address / Adresse e-mail : [email protected] (Antonio Gracco) *
International Orthodontics 2015 ; X : 1-13 http://dx.doi.org/10.1016/j.ortho.2015.03.013
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Introduction
Introduction
Dentigerous cyst is one of the most common lesions of the jaws [1]. It is an odontogenic lesion originating with the expansion of the follicle surrounding the crown of impacted, embedded or unerupted teeth [2]. Expansion of the dental follicle is caused by accumulating fluid between the tooth crown and the reduced enamel epithelium. The enlargement of the cyst is progressive and generally painless. This type of cyst evolves slowly and may be present for several years before being noticed. It may result in destruction of bone, displacement of adjacent teeth and resorption of their roots and may prevent eruption of cyst-associated permanent teeth [3–5]. Surgical enucleation of the dentigerous cyst combined with extraction of the cyst-associated impacted or unerupted tooth is the standard treatment but it is not always the best choice in young patients [6,7]. Marsupialization offers an alternative conservative treatment because it is less invasive, preserves the tooth and provides potential for the tooth to erupt into the oral cavity, provided space is available [8,9]. After marsupialization, orthodontic traction of the impacted tooth is often performed to bring the cyst-associated tooth or an ectopic tooth into the dental arch [10,11].
re repre sente l’une des le sions de la ma ^choire Le kyste dentige pandues [1]. Il s’agit d’une le sion forme e par les plus re l’expansion du sac folliculaire entourant les couronnes de es ou non e volue es [2]. La croissance dents incluses, enclave e par l’accumulation de fluide entre la du follicule est provoque pithe lium ame laire re duit. couronne dentaire et l’e ne ralement L’agrandissement du kyste est progressif et ge volution de ces kystes est lente et peut durer indolore. L’e es sans e ^tre remarque e. Elle peut donner lieu plusieurs anne placement a` une destruction de la substance osseuse, a` un de sorption de leurs racines et des dents avoisinantes et a` la re ^cher l’e ruption des dents permanentes associe es peut empe thode de traitement standard consiste en au kyste [3–5]. La me nucle ation du kyste dentige re combine e a` l’extraction de la l’e volue e associe e au kyste. Cependant, ce dent incluse ou non e pour les jeunes traitement n’est pas toujours recommande patients [6,7]. La marsupialisation offre un traitement alternatif conservateur qui est moins invasif, conserve la dent et potenmergence dans la cavite buccale si on dispose de tialise son e s la marsupialisation, on suffisamment d’espace [8,9]. Apre de souvent a` une traction orthodontique de la dent proce e au kyste ou une dent incluse pour amener la dent associe ectopique sur l’arcade dentaire [10,11].
Case history
Etude de cas
A 15-year-old boy was referred for treatment for late maxillary teeth exfoliation. Intraoral clinical examination of the upper arch revealed the persistence, on the right, of the deciduous canine and the second deciduous molar and, on the left side, just the deciduous canine. A painless, hard swelling was localized in the right posterior maxillary buccal region (fig. 1). Panoramic X-ray revealed the presence of a large translucent, uniloculated area with well-defined margins on the maxillary right side containing the unerupted maxillary canine, and first and second bicuspids. On the left side, the maxillary canine was impacted (fig. 2). Computerized axial tomography showed more precisely the lesion that had virtually reduced the right maxillary sinus to a gaping hole (fig. 3). Lateral radiographic examination and cephalometric tracing revealed a skeletal class II open bite malocclusion (fig. 4, Table I).
te adresse pour traitement en Un gar¸con de 15 ans nous a e raison d’un retard d’exfoliation d’une dent maxillaire. L’examen ve le la persistance, clinique intraoral de l’arcade maxillaire re me molaire de lait a` droite, de la canine de lait et de la deuxie ^ te gauche, on n’observe que la canine de lait. alors que, du co faction dure et douloureuse est situe e poste rieureUne tume ^ te vestibulaire maxillaire droit (fig. 1). Le panorament du co ve le la pre sence d’une importante zone radioclaire mique re finies du co ^ te maxillaire unilobulaire avec des limites bien de volue e et les predroit contenant la canine maxillaire non e re et deuxie me pre molaires. Du co ^ te gauche, on note la mie canine maxillaire incluse (fig. 2). La tomographie axiale rique, plus pre cise, re ve le que la le sion a presque re duit nume ante (fig. 3). le sinus maxillaire droit a` une ouverture be ral et le trace ce phalome trique L’examen radiographique late sence d’une malocclusion squelettique de montrent la pre ance (fig. 4, Tableau I). classe II avec be
Treatment objectives
Objectifs du traitement
Our first aim was to recover the affected teeth after marsupialization of the dentigerous cyst. Another treatment option could have been to perform complete surgical enucleation of the cyst with the associated impacted maxillary teeth in order to replace them with implants. However, because of the patient’s age, this method would have entailed a significant reduction in maxillary growth and in alveolar process bone
cupe rer les dents affecte es par Notre premier objectif est de re s marsupialisation du kyste dentige re. Un autre le kyste apre a` re aliser une e nucle ation traitement possible aurait consiste te du kyste ainsi que des dents maxillaires incluses comple pour les remplacer par des implants. Cependant, en raison ^ge du patient, il se produirait alors une re duction signifide l’a s cative de la croissance maxillaire et des dimensions du proce
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[(Fig._1)TD$IG]
Fig. 1: a–i: pretreatment photographs. Fig. 1 : a–i : vues avant traitement.
dimensions before the end of growth, precluding the possibility of implant placement. Transverse maxillary growth is dependent on pneumatization of the maxillary sinus: surgical cyst enucleation would have compromised maxillary growth and drastically mutilated the permanent dentition. The second aim was to correct the dentoskeletal malocclusion. Orthodontic treatment was performed after resolution of the cyst-related problems.
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olaire avant la fin de la pe riode de croissance, interdisant alve ainsi le placement d’implants. La croissance maxillaire transe a` la pneumatisation du sinus maxillaire. versale est lie nucle ation chirurgicale du kyste compromettrait la croisL’e graderait de fa¸con drastique la densance du maxillaire et de me objectif consiste a` corriger la ture permanente. Le deuxie malocclusion dentosquelettique. Le traitement orthodontique alise apre s correction des proble mes lie s au kyste. est re
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[(Fig._2)TD$IG]
Fig. 2: Pretreatment panoramic radiograph. Fig. 2 : Panorex avant traitement.
Treatment progress
Evolution du traitement
The surgical procedures began with the extraction of the upper right side deciduous teeth (canine and second molar), reflection of a mucoperiostal flap and removal of the bone overlying the cyst (fig. 5). The “roof” of the cyst was removed and the surrounding mucoperiosteum was sutured to the margins of the cyst wall after evacuation of the contents. Tissue from the exposed membranous wall was sent to the laboratory for histologic examination, which confirmed the diagnosis of dentigerous cyst. The wound was kept irrigated and cleaned during
Les interventions chirurgicales commencent par l’extraction, ^ te droit, des dents de lait maxillaires (canine et deuxie me du co molaire) suivie de la re flexion d’un lambeau pe rioste et de pre section de l’os surplombant le kyste (fig. 5). Le « toit » du la re et le mucope rioste environnant est kyste est ensuite incise aux bords de la paroi kystique apre s drainage de ses suture e contenus. Les tissus de la paroi membraneuse expose s au laboratoire pour analyse histologique sont adresse re. La plaie est qui confirme le diagnostic de kyste dentige
Table I
Tableau I
phalome trique avant traitement. Analyse ce
Pretreatment cephalometric analysis.
Normal Skeletal / squelettique S-N-A S-N-B A-N-B S-N/ANS-PNS S-N/Go-Gn ANS-PNS / Go-Gn Dental / Dentaire U1/ANS-PNS L1/Go-Gn L1-A-Pg (mm) Overjet (mm) Overbite (mm) U1/L1
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82 W 3.5 80 W 3.5 2 W 2.5 8 W 3.0 33 W 2.5 25 W 6.0 110 W 6.0 94 W 7.0 2 W 2.0 3.5 W 2.5 2 W 2.5 132 W 6.0
Pretreatment / Avant traitement 85 80 5 3 37 34 100 81 1 mm 3 mm 1 mm 145
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[(Fig._3)TD$IG]
Fig. 3: a–e: pre-operative computerized axial tomography. rique pre ope ratoire. Fig. 3 : a–e : tomographie axiale nume
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[(Fig._4)TD$IG]
Fig. 4: Pretreatment headfilm. le radiographie avant traitement. Fig. 4 : Te
three months by daily irrigations through the open surgical window. These measures relieved pressure from inside the cyst and the cavity was gradually obliterated by apposition of soft and bone tissue to close the defect [12]. Six months after marsupialization, the upper right canine and the first and second bicuspids were surgically disimpacted because they had not erupted spontaneously. The closed-flap
[(Fig._5)TD$IG]
e et nettoye e pendant trois mois avec des maintenue irrigue ^tre chirurgicale irrigations quotidiennes passant par la fene cautions diminuent la pression exerce e entrouverte. Ces pre est graduellement oblite re e par appopar le kyste et la cavite sion [12]. sition de tissus mous et osseux qui referment la le s la marsupialisation, la canine et les premie re et Six mois apre me pre molaires supe rieures droites, toujours non deuxie volue es, sont de sincluses chirurgicalement. La technique e
Fig. 5: Post-marsupialization intraoral lateral view. rale intraorale apre s marsupialisation. Fig. 5 : Vue late
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[(Fig._6)TD$IG]
Fig. 6: a, b: surgical disimpaction of upper right teeth. sinclusion chirurgicale des dents maxillaires droites. Fig. 6 : a, b : de
[(Fig._7)TD$IG]
Fig. 7: a–c: orthodontic traction of upper right teeth through the closed-flap. . Fig. 7 : a–c : traction orthodontique des dents maxillaires droites au travers du lambeau ferme
technique and subsequent orthodontic traction were used [13] (fig. 6). The erupted maxillary incisors, the upper left teeth and the right first and second molars were bonded with a Damon appliance. Brackets were bonded on the right canine and first and second bicuspids through the surgical window access and then extruded by tying the brackets directly to the .01400 CuNiTi archwire using long metal ligatures so as to cause the archwire to deflect. Restitution of the deflection force pulled the teeth with a continuous force without having to change ligatures. At the same time, space was created to allow eruption of the impacted teeth to their proper position (fig. 7). Three months after surgical dental recovery, the lower arch was bonded and, four months later, both the upper left and right canines were disimpacted (fig. 8). In this case, the flap was repositioned and sutured apically to the cementoenamel junction. During treatment, vertical elastics were used (fig. 9) and radiographic records were obtained to verify the accuracy of the orthodontic movements. After 48 months, the appliance was removed and a bonded fixed retainer was used in both arches: from canine to canine in the lower arch and from the right canine to left lateral incisor in the upper.
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suivie d’une traction orthodontique est a` lambeau ferme e [13](fig. 6). Les incisives maxillaires, les dents utilise rieures gauches et les premie re et deuxie me molaires supe rieures droites sont appareille es avec des attaches supe s a` la canine droite et aux preDamon. Les boıˆtiers sont relie re et deuxie me pre molaires au travers de la fene ^tre chirmie gresse es en attachant les urgicale. Les dents sont ensuite e boıˆtiers directement au fil .01400 CuNiTi avec de longues ligatalliques afin d’ame nager une de flection de l’arc. La tures me flection tracte les dents restitution continue de la force de de ^me temps, l’espace sans avoir a` changer les ligatures. En me e permettant l’e ruption des dents incluses a` leur place est cre sur l’arcade (fig. 7). s la re cupe ration de la chirurgie, l’arcade Trois mois apre rieure est appareille e et quatre mois plus tard, les canines infe senclave es (fig. 8). Chez maxillaires droite et gauche sont de et suture en apical de la ce patient, le lambeau est repositionne mentoame laire. jonction ce lastiques verticaux sont utilise s pendant le traitement Les e s radiographiques sont obtenus pour (fig. 9) et des cliche rifier l’exactitude des mouvements orthodontiques. ve s 48 mois, l’appareil est de pose et une contention fixe Apre e est place e aux deux arcades, de canine a` canine a` l’arcolle rieure et de la canine droite a` l’incisive late rale cade infe rieure. gauche a` la supe
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[(Fig._8)TD$IG]
Fig. 8: Disimpaction of non-cyst-associated upper left. sinclusion d’une dent maxillaire gauche non associe e au Fig. 8 : De kyste.
[(Fig._9)TD$IG]
Fig. 9: a–i: orthodontic treatment progress with vertical elastics. volution du traitement orthodontique utilisant des e lastiques verticaux. Fig. 9 : a–i : e
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[(Fig._10)TD$IG]
Fig. 10: a–h: posttreatment photographs. s traitement. Fig. 10 : a–h : vue apre
[(Fig._1)TD$IG]
Fig. 11: Posttreatment panoramic radiograph. s traitement. Fig. 11 : Panorex apre
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[(Fig._12)TD$IG]
Fig. 12: Posttreatment headfilm. le radiographie apre s traitement. Fig. 12 : Te
Table II
Tableau II
phalome trique apre s traitement. Analyse ce
Posttreatment cephalometric analysis.
Normal Skeletal / squelettique S-N-A S-N-B A-N-B S-N/ANS-PNS S-N/Go-Gn ANS-PNS/Go-Gn Dental / dentaire U1/ANS-PNS L1/Go-Gn L1-A-Pg (mm) Overjet (mm) Overbite (mm) U1/L1
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82 W 3.5 80 W 3.5 2 W 2.5 8 W 3.0 33 W 2.5 25 W 6.0 110 W 6.0 94 W 7.0 2 W 2.0 3.5 W 2.5 2 W 2.5 132 W 6.0
traitement Postreatment / Apres
84 82 2 2 33 31 123 88 4 mm 3 mm 1 mm 117
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[(Fig._13)TD$IG]
Fig. 13: a–i: follow-up photographs 14 months after end of treatment. s la fin du traitement. Fig. 13 : a–i : vues de suivi 14 mois apre
Treatment results
sultats de traitement Re
Our treatment induced physiological maxillary growth and a well-intercuspidated class I occlusion with coincident dental and facial midlines (figs. 10–12, Table II). All teeth showed normal vitality. Periodontal tissues were influenced by poor oral hygiene. The orthopantomogram showed sufficient root parallelism even though some teeth had an unusual shape. After 14 months, we were able to confirm the stability of the results (fig. 13).
la croissance physiologique du Notre traitement a stimule maxillaire et une occlusion de classe I avec une excellente dianes intercuspidation et un bon alignement des lignes me faciales et dentaires (fig. 10–12, Tableau II). Toutes les dents normale. Les tissus parodontaux ont e te affichent une vitalite s par une hygie ne buccale de ficiente. Le panorex affecte ve le un paralle lisme radiculaire suffisant me ^me si plusieurs re s 14 mois, on peut dents ont une forme inhabituelle. Apre cier la stabilite des re sultats (fig. 13). appre
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Discussion
Discussion
Dentigerous cysts are the most common type of developmental odontogenic cyst [1]. This kind of cyst occurs most frequently in the mandibular third molar or maxillary canine regions, followed by mandibular premolars, supernumerary teeth and, rarely, the central incisors [10]. Generally, dentigerous cysts are painless but may cause facial swelling and delayed tooth eruption. They may progress slowly for many years without being noticed and can give rise to destruction bone, displacement of adjacent teeth and resorption of their roots and prevent eruption of the cyst-affected permanent teeth [2–6]. The standard treatment of a dentigerous cyst is surgical removal and extraction of the cyst-associated impacted or unerupted tooth [4,7]. However, marsupialization should be considered when tooth displacement and great loss of bone have occurred. With marsupialization, formation of new bone is stimulated because of the decreased intracystic pressure and the cyst-affected teeth can erupt spontaneously into the arch, provided there is sufficient space [8,9].
res constituent le type de kyste de Les kystes dentige veloppement odontoge ne le plus fre quent [1]. Ils se produide quemment dans les re gions de la troisie me sent le plus fre molaire mandibulaire et des canines maxillaires, suivies des molaires mandibulaires, des dents surnume raires et, rarepre ne ralement, les kystes ment, des incisives centrales [10]. Ge res sont indolores mais peuvent provoquer une dentige faction faciale et un retard d’e ruption dentaire. Ils peuvent tume voluer lentement pendant de longues anne es sans e ^tre e s et donner lieu a` une destruction osseuse, un remarque placement des dents avoisinantes et une re sorption de de ^cher l’e ruption des dents perleurs racines, et peuvent empe es au kyste [2–6]. Le traitement standard manentes associe re consiste en l’ablation chirurgicale du d’un kyste dentige volue e associe e kyste et l’extraction de la dent incluse ou non e [4,7]. Cependant, il conviendrait d’envisager la marsupialisaplacement dentaire et une tion lorsqu’il s’est produit un de ^ce a` la marsupialisation, la forperte osseuse importants. Gra e en raison de la re duction de la mation de l’os est stimule es au kyste peuvent pression intrakystique et les dents associe ment trouver leur place sur l’arcade a` condition de spontane disposer d’un espace suffisant [8,9]. nient majeur de cette technique chirurgicale provient L’inconve s in situ. Me ^me si l’e chantillon des tissus pathologiques laisse au laboratoire pour analyse histologique, tissulaire est envoye siduels peuvent encore he berger une le sion plus les tissus re cet inconve nient, nous avons de cide de agressive [14]. Malgre ^ge du traiter ce cas par marsupialisation en raison du jeune a tait important et avait de ja` patient et du fait que le kyste e place trois dents permanentes. de lai de 3 mois avant de de cider d’une Nous proposons un de extraction ou d’un recours a` une traction orthodontique. Ce tre cissement du temps d’attente est critique puisque le re ruption de la dent, me ^me kyste peut, a` lui seul, promouvoir l’e tement si la racine de la dent permanente incluse est comple e [15]. forme sent, six mois apre s la marsupialisation, la Dans le cas pre me pre molaire supe rieures ont fait canine droite et la deuxie sinclusion chirurgicale en raison de leur nonl’objet d’une de ruption spontane e. Le traitement orthodontique est re serve e cupe rer, aligner et niveler les dents et pour au cas ou` il faut re peaufiner l’occlusion dans ce cas de classe II hyperdivergent.
The major disadvantage of this surgical technique is the pathologic tissue left in situ. Even if a tissue sample is sent to the laboratory for histological examination, there is still the possibility of a more aggressive lesion in the residual tissue [14]. Despite this drawback, we decided to treat this case by marsupialization because the patient was young and because the cyst was large and had caused displacement of three permanent teeth. A period of 3 months after marsupialization is suggested as essential before deciding whether to extract or use orthodontic traction. This delay is critical because cyst shrinkage can promote tooth eruption, even if the root of the permanent impacted tooth is completely formed [15]. In our case, six months after marsupialization, the upper right canine and first and second bicuspids were surgically disimpacted because they had not erupted spontaneously. Orthodontic treatment was used to correct, align and level the teeth and refine this case of class II open bite occlusion.
Conclusions
Conclusions
This paper discusses successful use of marsupialization combined with orthodontic treatment for treating cyst-associated teeth, included permanent teeth, and to resolve a class II open bite malocclusion.
sente l’utilisation re ussie de la marsupialisation Cet article pre e au traitement orthodontique pour traiter des dents associe es a` un kyste et pour re soudre une classe II incluses associe ance. avec be
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Disclosure of interest
claration d’inte re ^ts De
The authors declare that they have no conflicts of interest concerning this article.
clarent ne pas avoir de conflits d’inte re ^ ts en Les auteurs de relation avec cet article.
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