8/2/2019 Cs 5 Dentigerous

1/4

ORIGINAL ARTICLE

Dentigerous cyst of the maxilla withimpacted tooth displaced into orbitalrim and floorM orton Litvin, DDS; Dom enic Caprice, DM D; Leonard Infranco, DM D

AbstractWe report a case of dentigerous cyst ofthe maxilla andmaxillary sinus that caused the ectopic displacemen t o fanunerupted tooth into the orbital rim and floor. After anincisional biopsy, ma rsupialization ofthe lesion prom otedits involution and stimulated osteogen esis. This in turnsimplified the surgical enucleation ofthe specimen an dremov al ofthe uner upted tooth without the excessive lossofthe bony contours ofthe maxilla.IntroductionDentigerous cysts surrounding impacted teeth oftendisplace these teeth into ectopic positions. In the ma n-dible, they have been reportedly found in the symphysis,body, angle, corono id process, and the condylar neck.In the maxilla, these teeth are often displaced intothe maxillary sinus.' ' They have been reported to belocked into the ostiomeatal complex,'* piriform wall,and occasionally the orb it itself.-^''The sequelae of thesecysts and ectopic teeth vary from obstruction of thesinus to blindness.'

Dentigerous cysts of the maxillary sinus, and theimpacted tooth within, are often easily removed viaa Caldwell-Luc proced ure. However, removal of largelesions may require extensive surgery, the complica-tions of which can include aesthetic and functionaldeficits.Marsupialization is a method of exteriorizing cystic

From the Department of Oral and Maxillofacial Surgery, University ofPennsylvania School of Dental M edicine, Philadelphia (Dr. Litvin),and an oral and maxillofacial su rgery private practice, Vineland.N .J.(Dr. Caprice and Dr. Infranco).

Corre spon ding au thor : Morto n Litvin, DD S, Clinical Professor of OralSurgery and Pharmacology, Department of Oral and MaxillofacialSurgery, University of Pennsylvania School of Dental M edicine, 240S.40th St., Philadelphia, PA 19104. Phone: (856) 692-0399; fax:{856)692-4845; e-mail: L2docs4^comcast.net

lesions to facilitate decompression and involution,thereby simplifying their removal or in some caseseven allowing for the complete resolution ofthe cystwithout the need for secondary surgery. Marsupializa-tion has been reported as a definitive treatment forextensive cysts, including the more aggressive and highlyrecurrent odontogenic keratocyst.*^ When a secondarysurgery is required for the definitive treatment of a le-sion, previous marsupialization often affords thelux uryof a less invasive surgery, thereby reducing surgicalcomplications such as oroantralfistula,oronasal fistulanerve injuries (particularly to the inferior alveolar andlingual nerves), excessive bleeding, and mandibularfracture. It also minimizes the surgical defects causedby extensive bone removal, and it provides access fora biopsy specimen for a definitive diagnosis.

In this article, we report a case of dentigerous cystof the maxilla and maxillary sinus that caused theectopic displacement of an unerupted tooth into theorbital rim and floor.Case reportA 57-year-old black woman was referred to us by herdentist on Nov. 25,2003, for evaluation of an enlargedsoft swelling of her right maxilla and face. At the timeof her presentation, she was healthy, well-nourished,and in no acute distress. Head an d neck examinationrevealed that her extraocu lar m uscles were intact. Herpupils were equal, round, and reactive to light accom-mo dation, and there was no evidence of diplopia. Hernares were patent bilaterally, and her septum was atmidline. An intraoral examination detected an expansileswelling of her right posterior maxilla (figure 1). Theswelling was fluctuant to bimanua l palpation, indicat-ing buccal and palatal cortex destruction. The patienthad no other symptoms, and the results of routinelaboratory tests were within normal limits.

8/2/2019 Cs 5 Dentigerous

2/4

DENTIGEROUS CYST OF THE MAXILLA WITH IMPACTED TOOTH DISPLACED INTO ORBITAL RIM AND FLOOR

Figure 1. At presentation, the patient exhibits an enlarged rightposterior maxilla, with buccal and palatal expansion.

A panoramic radiograph revealed that a large uni-locular radiolucency ( -1 0 x 1 2 cm) had encompassedthe right maxilla from the first premolar posteriorlyto the tuberosity (figure 2, A). A tooth was visibleat the superior aspect of the lesion. According tothe radiology report, computed tomography (CT)of the maxilla identified "a large lesion of the rightmaxilla consistent with a dentigerous cyst" (figure 2,B). Three-dimensional reformatted CT showed theextent of destruction and ectopic displacement of thetooth into the right infraorbitai rim and o rhital floor(figure 2, C).

The patient was taken to the operating room on Dec.16,2003. A 2 X 2-cm op ening into the right maxillaryan trum was created, and care was taken to no t violatethe cyst wall (figure 3, A). Aspiration of the cystic con-tents yielded approximately 20 ml of a brownish fiuid.Bimanual palpation and visual inspection suggested ahigh likelihood of a gross deformity of the maxilla ifthe lesion were to be enucleated primarily. Therefore,the decision was made to marsupialize the lesion.Throug h the an tral opening, several biopsy specimensof the cyst wall were obta ined . Through the lesion itself,the crown of an impacted tooth, locked solidly intothe orbital rim and floor, was palpated. The edges ofthe cyst opening were sutured outwardly to the buccalwindow. Following irrigation, the entire lesion waspacked with '/2-inch gauze impregnated with bismuthsubnitrate, iodoform, and petrolatum paste.

According to the h istology rep ort, the biopsy speci-mens showed "a stroma of delicatebundles of imm aturecollagen fibers interspersed by active fibrocytes andnumerous dilated capillaries. Numerous cholesterol

Figure 2. A: Panoramic radiograph shows the large unilocular ra-diolucency of the right maxilla and the ectopic tooth in the superioraspect of the lesion. B: CT reveals the complete destruction of theright posterior maxilla and the presence of a unilocular fluid-filledmass. C: Three-dimensional CT reconstruction show s the crownof the tooth in the right intraorbital rim and the root perforatingthe orbital fioor.

8/2/2019 Cs 5 Dentigerous

3/4

LITVIN, CAPRICE, INFRANCO

Figure 3. A: The lesion is marsupializcd. B: Six weeks later, the surgical site is welt heated, and the contours are more normal-appearing.

crystals with associated giant cells were noted. Nomalignant features were noted. The specimen ap-peared to be consistent with a denuded cyst wall, butno lining epithelium was observed." Com plete excisionof the entire lesion with follow-up examinations wasrecommended.The patient underwent weekly changes of packingthat were eventually replaced by daily irrigations of thelesion until M arch 23 , 2004, at which time the fistulawas closing. Repeat CT demo nstrated bone depositionin the maxilla, as well as a slight migration of the toothaway from the o rbitalfloor.Bimanual palpation of themaxilla revealed improving firmness along the rightposterior palate.The patient was then returned to the operatingroom, and the lesion was completely enucleated viaa Caldwell-Uic incision. The impacted tooth, withsomewhat divergent roots, was carefully rem oved fromthe orbital rim and floor with judicious bone removal.The infraorbital nerve was visualized and appeared tobe intact. The Caldwell-Luc incision was closed, andattention was then directed to the residual oroantralfistula, which was excised and closed primarily.The results ot surgical pathology were consistent withthe biopsy findings obtained at the time of marsupial-ization. According to the repo rt, ''stratified squam ousepithelium, foci of lipogranuloma, and extensive hy-alinization offibrousconnective tissue" were observed,confirming the diagnosis of a dentigerous cyst.The patient healed uneventfully, and no oroantralcommunication was observed (figure 3, B). No com-plications were enco untered.

DiscussionIn this case, marsupialization was successfully used tominimize the amount of maxillary destruction andsurgical morbidity that might have resulted from theimmediate enucleationofthe iesion. Although it wouldhave been of interest to allow more time for furtherinvolution and to assess whether the tooth would mi-grate into the oral cavity without a secondary surgery,it can be quite problematic to maintain the patencyof these sites intraorally. In this case, marsupializa-tion allowed us to obtain several biopsy specimensfor treatment planning and provided some time forosteogenesis, particularly of the palatal aspect of thisextensive lesion.References

1. Mody RN, Sathawane RS, Samdani D. Dentigerous cyst: Report ofan unusual case. Dent Update t993;22(3);124-6.2. Gijnbay MU, Lom^aii G, Ozaksoy D, et al. Ectopic teeth in themaxillary sinus: Diagnosis and treatment. Dent Update 1995;22(4):146-8.3. Frer AA, Friedman AL, Jarrett WJ. Dentigerous cysts involvingthe maxillary sinus. Oral Surg Oral Med Oral Pathol 1972;34{3):378-ao.4. Hasbini AS, Hadi U, Ghafari J. Endosco pic removal of an ectopicihirdmolarobstructingtheosteomeatalcomplex. Ear Nose ThroatI200I;80(9):667-70.5. Golden AL, Foote I, Lally E, et al. Den tigerous cyst of the m axillarysinus causing elevation of the orbital floor. Report of a case. OralSurg Oral Med Oral Pathol l981;S2(2):133-6.6. f-erber EW. Ectopic supernumerary tooth, imbedded in superiorwall of left maxillary antrum. J Calif Dent Assoc 1972;48( 1 }:28-9.7. Savundranayagam A. A migratory third m olar erupting into thelower border of orb it causing blindn ess in the left eye. Aust Dent II972;17{6):418-2O.8. Pogrel MA, Jordan RC.M arsupiaiization as adefinitivetreatment fortheodontogenic keratocyst.J OralMaxillofac Surg2004;62(6):651-5 ;discussion 655-6.

8/2/2019 Cs 5 Dentigerous

4/4