Case Report / / LASER TREATMENT OF DENTIGEROUS CYST 21 Laser-assiste T reatment o a Den tiger ous C yst: Case Rep ort Juan R. Boj, DDS, PhD 1 • Clervie Poirier, DDS, P hD 2 • Miguel Hernandez, DDS, PhD 3 • Enric Espasa, D DS, PhD en ti ge ro us or o icu ar cyst s are ma xi ar y en ig n o on- og enic cy st s genera y a ssociate wi t t e c ro wn o an im- acte , em e e , or unerupte permanent toot . 1,2 e cyst enc osing t e u nerupte toot s c rown is attac e o t e to ot s cervica re gi o n. 3 e eru pti on cys t is t e na ogous case w en it ap pear s in t e so t tissue, s ort y e- or e toot er up ti o n. es pi te t e re ei ng a nu m er o t e o- ies a out t ei r o ri gi n, ot se em to re su t rom t e s ep ar a- ion o t e epit e ium rom t e ename o t e toot s crown due to an accumulatio n o blood or other uid i n a d ilated o icu ar space. n t e enta i te ra tu re , t e se c ys ts a re c on si e re to e e secon mo st co mmon o on to genic c ys ts o t e jaws, a te r a icu ar cysts. 7 ey are more common in ma e pat ien ts an sually ap pear du ring th e seco nd or t hird decade o li e. 1,8 n ixed dentition, they represent less than 9% o dentigerous cysts. In 75% o cases, they are loc ated in t he mandi ble.10 In ord er, th e teeth most o ten a ecte d are: (1) man dibula r hird molars; (2) maxillary third molars; and (3) maxillary ermanent canines. , 11 ey ave a so een re po r te in t e an i u ar secon premo ars. 3 ese esions are o ten etec te ur ing a routine ra io- rap ic examination. is is ecause entigerous cysts are typically painless, unless there is acute in ammatory exa- cer ation 1, 7 ,8 (ie, in mixed dentition when a necrotic primary tooth in ects the ollicl e o the perman ent successor). 3,9 ain designa ted s uch cysts as in ammatory ollicu lar cy sts. 12 ain s a s ig n o seco n ar y i n ec ti on on t es e ste ri e c ys ts . 13 t e cyst reac es a arge size 14 (>2 cm in diameter), we may ob- serve ac ia swe in g ue to its po te ntia or ex pa n in g t e cor tic a one. 1,7,9 e nt i ge r ou s cy sts are usua y so ita ry , an t e ra i o- r ap ic pa tt e rn is c a ra c te ri ze y a s ym me tr ic , we - e- ne , uni ocu ar ra io ucent esion surroun ing t e un- erupte toot s crown, w ic can isp ace a jacent teet an cause root resorption. , Clinical examination and radiography provide a prelimi- ary diagnosis, but a de nitive diagnosis requires histopath- o og ic a ana ys i s. 7 Di erenti al diagno ses should include: (1) hyperplasia o the tooth ollicl e 1 ; (2) ameloblastic broma 1,1 ; (3) unicystic ameloblastomas 16 (4) glandular odontogenic cyst 17 ; (5) odontogenic keratocyst 18 ; and (6) adenomatoid o ont oge nic tumor . 19 Several treatments have been proposed, including: 1. tota enuc ea ti on 2. mars upi alization ; 3. decompression opening the cyst and ensuring continual drainage ,, ; 4. combin ation o marsupializat ion or d ecompr ession and enucleation , , and 1 Dr. Boj is chairman, 2 Dr. Poirier is associate p ro essor, 3 Dr. Hernandez is pro essor, and 4 Dr. Espasa is pro essor, all at Department o Pediatric Dentistry , Dental School, University of Barcelona, Spain. Correspond with Dr. Boj at [email protected]bs tr ct:Dentigerous cysts are benign maxillary odontogenic cysts associated with the crown of an unerupted tooth. They can expand the ortical bone to such an extent that they cause displacement of teeth and root resorption in the adjacent teeth. The purpose of this report was o describe the clinical case of a dentigerous cyst in a mandibular permanent molar of a 6-year-old child. The cyst caused the displaceme nt of the ud of the permanent second molar and root resorptio n of the primary second molar. The cyst was treated b y: 1 mucous fene stration using an rbium laser: (2) drainage of the fluid content; and (3) curettage of the bone cavity. The injury was successfully resolved in just 5 months with: (1) bone regeneration; (2) the repositioning of the displac ed bud; and (3) correct eruption of the affected tooth. (Pediatr Dent 2007;29:521-4) eceived December 6, 2006 /Revision Accepted February 20, 2007. : , ,
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Case Report
PEDIATRIC DENTISTRY 29 / NO NOV / DEC 07
LASER TREATMENT OF DENTIGEROUS CYST 21
Laser-assiste Treatment o a Dentigerous Cyst: Case Report Juan R. Boj, DDS, PhD1 • Clervie Poirier, DDS, PhD2 • Miguel Hernandez, DDS, PhD3 • Enric Espasa, DDS, PhD4
Dentigerous or follicular cysts are maxillary benign odon-togenic cysts generally associated with the crown of an im-pacted, embedded, or unerupted permanent tooth.1,2 Thecyst enclosing the unerupted tooth’s crown is attachedto the tooth’s cervical region.3 The eruption cyst is the
nalogous case when it appears in the soft tissue, shortly be-ore tooth eruption. Despite there being a number of theo-
ries about their origin,5 both seem to result from the separa-tion of the epithelium from the enamel of the tooth’s crowndue to an accumulation of blood or other fluid in a dilatedollicular space.6
In the dental literature, these cysts are considered to bethe second most common odontogenic cysts of the jaws, afterradicular cysts.7 They are more common in male patients and
sually appear during the second or third decade of life.1,8 Inmixed dentition, they represent less than 9% of dentigerouscysts. In 75% of cases, they are located in the mandible.10In order, the teeth most often affected are: (1) mandibularthird molars; (2) maxillary third molars; and (3) maxillary
permanent canines.8,11 They have also been reported in themandibular second premolars.3
These lesions are often detected during a routine radio-graphic examination. This is because dentigerous cysts aretypically painless, unless there is acute inflammatory exa-cerbation1,7,8 (ie, in mixed dentition when a necrotic primarytooth infects the follicle of the permanent successor).3,9 Maindesignated such cysts as inflammatory follicular cysts.12 Painis a sign of secondary infection on these sterile cysts.13 If the
cyst reaches a large size14 (>2 cm in diameter), we may ob-serve facial swelling due to its potential for expanding thecortical bone.1,7,9
Dentigerous cysts are usually solitary, and the radio-graphic pattern is characterized by a symmetric, well-de-fined, unilocular radiolucent lesion surrounding the un-erupted tooth’s crown, which can displace adjacent teeth andcause root resorption. ,
Clinical examination and radiography provide a prelimi-nary diagnosis, but a definitive diagnosis requires histopath-ological analysis.7 Differential diagnoses should include: (1)hyperplasia of the tooth follicle1; (2) ameloblastic fibroma1,15;
bstr ct: Dentigerous cysts are benign maxillary odontogenic cysts associated with the crown of an unerupted tooth. They can expand the
ortical bone to such an extent that they cause displacement of teeth and root resorption in the adjacent teeth. The purpose of this report was
o describe the clinical case of a dentigerous cyst in a mandibular permanent molar of a 6-year-old child. The cyst caused the displacement of the
ud of the permanent second molar and root resorption of the primary second molar. The cyst was treated by: (1) mucous fenestration using an
rbium laser: (2) drainage of the fluid content; and (3) curettage of the bone cavity. The injury was successfully resolved in just 5 months with:
(1) bone regeneration; (2) the repositioning of the displaced bud; and (3) correct eruption of the affected tooth. (Pediatr Dent 2007;29:521-4)eceived December 6, 2006 / Revision Accepted February 20, 2007.
: , ,
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522 LASER TREATMENT OF DENTIGEROUS CYST
PEDIATRIC DENTISTRY V 29 / NO 6 NOV / DEC 07
5. decompression combined with extraction of the causativeinfected tooth in inflammatory cysts.3,9
This article describes the case of a dentigerous cysttreated with an Er, Cr:YSGG laser (erbium, chromium, yttri-um, scandium, gallium, and garnet; Waterlase-Biolase Tech-nology, San Clemente, Calif). This type of laser is a hydroki-
netic system that liberates photons in an air-water spray and works at a wavelength of 2,780 nm. The effect of this laser with its wavelength is favored by the water present in soft tis-sues.22 The laser’s energy is carried by a system of fiber opticsto a terminal point made of a sapphire crystal.23
Case report 6-year-old boy was brought to the Department of Pediatric
Dentistry at the Dental School of the University of Barcelona,Barcelona, Spain, because his family had noticed a swellingon his face at the mandible level on the right-hand side. Thepatient was asymptomatic and had no history of pain. The
medical history was noncontributory. In the extraoral examination, slight facial asymmetry wasobserved, with swelling at the right mandibular angle. There
was, however, no noticeable presence of submandibular orcervical adenopathy. Intraoral examination revealed a bluish
rea on the gingiva (Figure 1) above the unerupted perma-nent mandibular right first molar. There was little buccolin-gual expansion of the bone. The panoramic radiograph revealed a large unilocularradiolucency (osteolytic lesion) measuring 1.6 cm in diam-eter and associated with the crown of an unerupted perma-nent mandibular right first molar with open apices. There
was resorption of the distal root of the primary mandibularsecond molar and distal displacement of the permanent sec-ond molar bud (Figure 2). The lesion’s clinical appearance was compatible with adentigerous cyst.We decided to incise the upper limit of the
cyst to expose the cavity. A total of 36 mg of 2% lidocaine withepinephrine 1:100,000 in a mandibular block and buccal in-filtration was used for local anesthesia. The settings for thelaser were those recommended by the manufacturer for softtissue surgery (1.50 watts, 10% water, and 11% air). The sap-
phire point of the erbium laser usedto fenestrate the cystic membrane was
pplied 1 to 1.5 mm from the tissue formaximum cutting effectiveness.4 Thecystic content was an amber-yellowish
uid (Figure 3). A 2 x 2 mm fragmentof the cystic lesion was excised (inci-sional biopsy) for histological study. Ahypomineralized molar could be seenin the cavity (Figure 4). The surgi-cal opening was widened to enhance
ccess in order to aspirate the cys-tic content and curette the cyst cavitythoroughly. Histological examinationconfirmed the diagnosis of a dentiger-ous cyst with the following findings: a
Figure 2. Panoramic radiograph demonstrating a dentigerous cyst related to an uneruptedpermanent mandibular first molar, with displacement of the permanent second molar budand resorption of the distal root of the primary econd olar.
Figure 1. Clinical lesion demonstrating bluish appearance andhandpiece with sapphire tip of the erbium laser.
Figure . Initial ablation with the laser. The amber-yellowishcolor of the cystic liquid can be appreciated.
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PEDIATRIC DENTISTRY V 29 / NO 6 NOV / DEC 07
LASER TREATMENT OF DENTIGEROUS CYST 523
dense connective fibrous wall covered with a finelayer of nonkeratinized squamous epithelium and con-taining variable amounts of myxoid tissue and odontogenicepithelial remnants.
The patient was observed after surgical treatment, and nosymptoms or signs of recurrence were detected. Five months
fter treatment, a panoramic radiograph revealed that thecystic lesion had disappeared and there was new bone growthFigure 5). The unerupted molar had reached a proper posi-
tion in the arch without orthodontic traction. Bone regener-
tion was also observed around the resorbed root of the man-dibular primary second molar, which presented no signs ofthe pulp being affected. Furthermore, the permanent secondmolar’s bud had corrected its position within the bone. Theonly pathologic finding was that the molar associated withthe cyst was hypocalcified, while none of the other perma-nent molars was affected (Figure 6).
DiscussionThe case described presents all the typical characteristics of a
dentigerous cyst—they:1. are more frequent in men , ;
2. appear at the neck of an uneruptedtooth’s crown; 3. displace teeth; and
4. resorb roots as they grow.The discovery of a hypomineral-
ized molar in the cyst could be just a co-incidence, due to the high incidence ofthis anomaly in the last decade.
Early diagnosis of this type of cystin children is important, as growth canbe rapid and can cause bone fractures
nd deformation.1 Eruption cysts usu-
lly do not require treatment, and theffected tooth erupts normally. In the
case of dentigerous cysts, however, treatment is always nec-essary.4 Children have a much greater capacity than adults toregenerate bone and teeth with open apices have a greatereruptive potential.9,20,24 These factors should make one con-sider large dentigerous cysts in children as entities distinctrom those in adults, with much better prognosis for the
teeth involved. We employed conservative treatment. Exposing the cyst,
spirating the fluid content, and curetting the cavity provedto be suffi cient. The erbium laser provided a good vision of
the operational field, as we could take advantage of its coagu-lating effect, even though this effect is limited compared toCO2 lasers.25 It also provides the possibility of remodellingthe bone if necessary. 6,27 The antibacterial28 and anti-in- ammatory properties attributed to the laser may improve
postoperative prognosis. 9 The only medication the patientrequired was 200 mg of ibuprofen on the day of the surgery.No sutures had been used, and the soft tissues scarred quick-ly and without any problems.
Figure . Intraoperative appearance of the molar in the cystic cavity.Rough laser incisions with tissue tags can be seen. The margins of theincision were subsequently smoothed with the laser. A cleaner inci-sion margin could have been achieved by the use of a scalpel blade.
Figure . Panoramic radiograph months after surgery showing the resolution of the lesion.
Kozelj et al,9 Ertas et al,20 and Martinez et al 4 have alsopresented cases of conservative treatment in the mixed den-tition, which permitted spontaneous eruption of the affectedpermanent tooth. In these cases, complete ossification of thebony defect occurred in 1 or 2 years. In the present case, os-sification occurred in a shorter time since the origin was not
due to an infection of a primary tooth as in the cases present-ed by these other authors.
The laser technology currently available can consider-bly help in the treatment of some cases that require surgery
in pediatric dentistry.30 Erbium lasers are the most versatilefor pediatric dental patients, as they can be used for both soft
nd hard tissues. They are an additional tool for improvingnd modernizing the authors’ treatments.
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