|Year : 2012 | Volume
| Issue : 2 | Page : 127-130
Rehabilitation of benign pathological condition by dental implants
Ahmet F Misir1, Akif Türer2, Emel Bulut2, Mahmut Sümer2, Filiz Karagöz3
1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Bulent Ecevit, Zonguldak, Turkey
2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Ondokuz Mayis, Samsun, Turkey
3 Department of Pathology, Faculty of Medicine, University of Ondokuz Mayis, Samsun, Turkey
|Date of Web Publication||10-Oct-2012|
Ahmet F Misir
Bulent Ecevit Universitesi, Dishekimligi Fakultesi, Agiz Dis Cene Hastaliklari ve Cerrahisi Anabilim Dali, 67600, Kozlu, Zonguldak
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Dentigerous cysts are benign odontogenic cysts that arise from the dental follicle of an unerupted or developing tooth. They are the second most common odontogenic cysts after radicular cysts and account for approximately 24% of the jaw cysts. Patient may give the history of slowly enlarging swelling. A female patient aged 54 years came to our unit with a diffuse swelling on the left side of her face which was found to be dentigerous cyst on clinical, radiological and histopathological examination. The patient underwent enucleation with extraction of affected teeth leading to partial edentulous state without any pathological fracture of the mandible. Post-operatively after 8 months, adequate bone filling was noted. Implant-supported rehabilitation was done. The present case emphasizes the maintenance of the new bone formation without using any graft materials for the placement of dental implants and also the implant-supported rehabilitation has proven good results in benign pathological lesions.
Keywords: Dental implants, dentigerous cyst, enucleation, mandible
|How to cite this article:|
Misir AF, Türer A, Bulut E, Sümer M, Karagöz F. Rehabilitation of benign pathological condition by dental implants. J Dent Implant 2012;2:127-30
|How to cite this URL:|
Misir AF, Türer A, Bulut E, Sümer M, Karagöz F. Rehabilitation of benign pathological condition by dental implants. J Dent Implant [serial online] 2012 [cited 2023 Jun 8];2:127-30. Available from: https://www.jdionline.org/text.asp?2012/2/2/127/102233
| Introduction|| |
Cysts are lesions formed by a central cavity and are coated with a thin epithelium and a fibrous capsule. The lumen can be empty or can contain liquid of different origins.  Dentigerous cyst is born around the crown of an impacted tooth and is generated by the accumulation of fluid between reduced enamel epithelium and the surface of the tooth crown. 
Dentigerous cysts are the second most common odontological cysts and the most common developmental cysts of the jaws, being associated with the crowns of permanent teeth, especially unerupted mandibular third molars.  They are tentatively diagnosed on routine dental radiographs. Radiographically, the dentigerous cyst appears as a well-circumscribed, demarcated, unilocular, usually symmetric radiolucency attached at an acute angle to the cervical area/cementoenamel junction of an unerupted or impacted tooth.  Removal of the associated tooth and enucleation of the lesion are considered to be a definitive therapy in the management of dentigerous cysts.  Implant placement, after enucleation of jaw cysts is an acceptable and well-documented procedure in clinical practice. , This case report demonstrates the treatment of a large dentigerous cyst surgically by the enucleation technique alone, without any need for additional autogenous grafts or alloplastic materials to regain the integrity of bone structure. The patient was rehabilitated with dental implants after a relatively short period of healing. The implant-retained fixed prostheses functioned well throughout the 48-month evaluation time.
| Case Report|| |
A 54-year-old female patient consulted our Department of Oral and Maxillofacial Surgery clinic for the evaluation and assessment of a radiolucent lesion and swelling located at the left posterior region of her mandible in February 2008. The patient's general practitioner had noticed a radiolucent lesion on the periapical radiograph and, interpreted it as a cyst before referring the patient to our clinic.
Initial examination in the surgical office revealed a bony expansion of the inferior border and body of the mandible on the left side as well as calculus formation in the upper molar region with some serous discharge from the area of intraoral aspiration [Figure 1]. A panoramic radiograph revealed a large well-delineated, unilocular radiolucency of the left body and ramus of the mandible extending from the alveolar crest to the inferior border of the mandible, anteriorly to the first molar region and posteriorly to ascending ramus including the impacted third molar tooth [Figure 2]. The apices of left first molar were within the lesion and the pulp vitality test was negative. According to radiologic and clinical findings, the initial diagnosis was a dentigerous cyst. Aspiration of the cystic cavity with a no. 18 gauge needle yielded a straw-colored fluid and the histopathology report of incisional biopsy revealed the characteristic features of a dentigerous cyts. The surgical plan was the endodontic treatment of the first molar, and extraction of the third molar with enucleation of the lesion.
|Figure 1: The initial clinical view of the patient showing calculus formation in the upper molar region|
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|Figure 2: Preoperative ortopantomograph showing a well-demarcated large radiolusent lesion with an unerupted lower left third molar and involving the second molar roots|
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After endodontic treatment of the first molar, the cyst was totally enucleated with an intraoral approach and the third molar was extracted under general anesthesia. Intraoperatively however, resorption of the lingual aspect of bone and apicectomy of the second molar caused the tooth luxation. Extraction of the second molar was then preferable to leaving it. The inferior alveolar nerve sheath was visualized and carefully protected during the surgical procedure. A miniplate and screw set for internal fixation and reconstruction was ready during the operation in case of any pathological fracture of the mandible.
The patient was discharged, after having been given postoperative instructions for the administration of postoperative medication. On examining the patient the day following the surgery; other than visible bruising she had no discomfort and she reported no paresthesia. The patient was seen postoperatively at intervals of 7 days, 21 days, 3 months, and 7 months. Residual sutures were removed after 21 days.
The biopsy of the cyst wall revealed fibrous tissue lined with stratified squamous nonkeratinized epithelium and therefore confirmed the initial diagnosis [Figure 3].
|Figure 3: Photomicrograph showing inflamed cystic wall with non-keratinizing squamous epithelium H and E, ×100|
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Eight months after enucleation almost total disappearance of the radiolucency was noted. Two implants of 12,5 × 4 mm (SPI VECTO; Thommen Medical, Waldenburg, Switzerland) were inserted in the region of first and second left mandibular molar [Figure 4]. The bone formation on the buccal and lingual aspect of the defect was satisfactory and resulted in excellent primer stability of the implant. Three months later (12 months postsurgery) the implants were uncovered and restorative procedure was performed with fixed metal-ceramic crowns. The implants and the crowns have been functioning for 36 months postinsertion, with no clinical, and radiographic signs or symptoms observed or reported by the patient [Figure 5] and [Figure 6].
|Figure 4: Ortopantomograph showing the bone regeneration after 8 months, immediately after implant placement|
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|Figure 5: Clinical view of implant-retained fixed prostheses at the 3rd. year postoperatively|
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|Figure 6: Ortopantomograph showing implant-retained fixed prostheses after 3 years of final prosthetic recontruction|
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| Discussion|| |
Dentigerous cysts of the jaws are usually asymptomatic. They can cause swelling, alteration of the normal bone profile, paresthesia and are chance findings on dental radiographs taken for other reasons. The presence of any of these symptoms justifies an investigation for surgical cyst removal. The diagnosis of dentigerous cyst is based on a combination of clinical examination, radiographic findings, and histological features. , In the case presented here, the first molar tooth in this part of the mandible had already erupted and had been extracted some years before; therefore, nothing had been unexpectedly except calculus formation in the upper molar region.
The treatment approaches were based on patient age, cyst site and size, involvement of vital structures by the cyst, and the potential for normal eruption into occlusion of the impacted tooth involved. Aspiration with a 16- or 18-gauge needle was performed to confirm that they were dealing with cysts and not tumors, and these were followed by incisional biopsies to make definitive histological diagnoses. . The treatment involves enucleation and curettage of the cyst and extraction of the tooth involved, in case of third molars. The advantages of enucleation are one-stage surgery that has low recurrence rate and short healing period with or without bone grafting tecniques. , If the involved tooth is a canine, after the enucleation of the cyst, it can erupt spontaneously or it can be moved in the dental arch by means of an appropriate orthodontic treatment.  Another surgical option is decompression or marsupialization. It has been reported that the use of this technique may lead to a secondary bone regeneration followed by a reduction of the cyst volume. Nevertheless, a secondary surgery is often required in order to eradicate the possible recurrence of the lesion. ,, Minimal invasion, low morbidity, absence of severe complications such as infection, and fracture of the involved bone are some of the major advantages of decompression method.  However, there are some disadvantages icluding long healing period and discomfort of the patient due to the decompression stents.
Asymptomatic dentigerous cysts do not usually involve the mandibular canal and subsequently are easily separated from surrounding tissues and removed.  The surgery was undertaken under general anesthesia with enucleation and curettage for these reasons in this case any bone graft were used. Several studies have reported safe and regular bone healing after enucleation and simple closure of jaw cysts without using bone grafts even in cases of large defects. ,,, The complication rate for cyst enucleation, primary closure and perioperative antibiotic treatment seems to be less than 5%, even in defects measuring far more than 3 cm. ,, Despite the extension of the lesion, complications such as permanent bony defects or pathologic fractures did not occur in the present case.
There are still controversies on the use of graft materials before implant placement in large bony defects. Karamanis et al.  reported that the placement of small quantity of an osseoconductive bone substitute in a cyst defect after marsupialization is advantageous than autografting procedures. On the other hand, Cakarer et al.  reported that the resolution of the large defect of a dentigerous cyst, before implant insertion, is achieved without resorting to bone grafting procedures. The result of the present case is consistent with similar cases suggesting that the large cyst defects can be resolved without using graft materials before implant insertion.
Loss of bone height after large jaws lesion could represent a serious problem in all cases that, after cyst removal, should be treated by endosseous implant surgery to achieve a satisfactory implant-supported prosthetic rehabilitation.  The advantage of the chosen treatment plan were the short healing period including implant osseointegration period (less than 1 year) and the relative comfort of the patient especially one-stage surgery under general anesthesia.
There are only limited number of clinical reports describing the success rates of implants placed after surgical treatment of odontogenic cyst. , In the present case, the implant-retained fixed prostheses has been functioning successfully for more than 3 years, without any signs of discomfort. This shows us the implant-supported rehabilitation has proven good results in benign pathological lesions.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]