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Treatment of dentigerous cysts with a modified Hawley plate in children: report of two cases with radiographic results
ARTICLE IN PRESS
YBJOM-5802; No. of Pages 3
Available online at www.sciencedirect.com
ScienceDirect British Journal of Oral and Maxillofacial Surgery xxx (2019) xxx–xxx
Short communication
Treatment of dentigerous cysts with a modified Hawley plate in children: report of two cases with radiographic results J. Nohra a,∗ , A.R. Kassir a , H. Akel b , M. Dagher a a b
Periodontology Department, Faculty of Dental Medicine, Saint-Joseph University of Beirut, Lebanon Department of Esthetic and Prosthodontics, Faculty of Dental Medicine, Saint-Joseph University of Beirut, Lebanon
Accepted 20 September 2019
Abstract Dentigerous cysts in young adults may compromise the natural evolution of the dentition and can be treated surgically or non-surgically. We report the minimally-invasive treatment of dentigerous cysts in two young patients using a modified Hawley plate to avoid traumatic injury to anatomical structures, with up to four years’ follow up. © 2019 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: odontogenic cyst; pediatric patient; non-surgical treatment; marsupialization
Introduction Dentigerous cysts are common in young adults. They are the most common odontogenic cysts, are often related to immature, non-vital, deciduous teeth, and are usually associated with the crowns of unerupted teeth.1 If left undetected or untreated, they can spread, engulf and jeopardise contiguous teeth, and may lead to extensive destruction of bone with possible fractures in extreme cases. Enucleation with complete removal (without rupture of the membrane) is usually indicated for small cysts, though it is considered to be a traumatic approach that often leads to the loss of communicating teeth.2,3 Marsupialisation is indicated for larger cysts, which usually engulf a number of teeth buds, particularly in young patients.
∗ Corresponding author at: Periodontology Department, Faculty of Dental Medicine, Saint-Joseph University, 17-5208, Mar Mikhaël Beyrouth, 11042020, Beirut, Lebanon. Fax: +9611322506. E-mail address: [email protected] (J. Nohra).
We report the successful treatment of two patients with dentigerous cysts with a non-surgical approach that used a modified Hawley plate as a marsupialisation device.
Case report Case 1 A healthy 11-year-old girl was referred because of an abnormality seen on a plain radiograph. Clinically, the lower right deciduous second molar presented with an ill-adapted amalgam with buccal bony expansion. A unilocular radiolucency below tooth number 85 extended mesially, displaced tooth number 45, and shifted the mental nerve apically (Fig. 1). Under local anaesthesia, we extracted the right, primary, mandibular second molar atraumatically, and rinsed the site abundantly with saline. A modified Hawley plate, which had been made by the treating orthodontist, was inserted as a space maintainer and means of marsupialisation (Fig. 2 and Supplemental Fig. 2, online only). She was instructed to keep
https://doi.org/10.1016/j.bjoms.2019.09.019 0266-4356/© 2019 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: J. Nohra, A.R. Kassir, H. Akel, et al.. Treatment of dentigerous cysts with a modified Hawley plate in children: report of two cases with radiographic results. Br J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.bjoms.2019.09.019
YBJOM-5802; No. of Pages 3
2
ARTICLE IN PRESS
J. Nohra, A.R. Kassir, H. Akel et al. / British Journal of Oral and Maxillofacial Surgery xxx (2019) xxx–xxx
Case 2
Fig. 1. Initial panoramic radiograph showing the cystic lesion on the lower right side, implicating the bud of tooth # 45, and displacing the mental nerve.
A healthy 10-year-old boy presented with a swelling on the lower left side of his mandible. We restored the deciduous lower right second molar with a prefabricated metal crown, which included a volumetric increase of the buccal cortical plate. Radiographic examination showed a well-defined radiolucency that engulfed the mesial root of the first permanent erupted molar and the bud of the second premolar. We treated him using the same protocol as the previous patient. The 18-month follow-up panoramic radiograph showed normal eruption of the second lower right premolar and confirmed complete bony healing. The evolution of the treatment is shown in Supplemental Figures 4-6 (online only).
Discussion
Fig. 2. The modified Hawley plate. Note the protruding acrylic resin used for marsupialisation.
Fig. 3. Four-year panoramic view of the patient after treatment showing complete radiographic healing of the bone.
the appliance on even during meals and to rinse the site profusely with saline four times a day. She was seen weekly for 12 weeks, and the protruding part of the device was progressively trimmed. At eight months, panoramic radiography showed complete healing of the bone and a normal path of eruption (Supplemental Fig. 2, online only). The fouryear follow-up panoramic radiograph showed stable results (Fig. 3).
Dentigerous cysts usually occur between the ages of 1020 years,4 predominantly in the posterior mandible.5 Both patients fell into this category, and in both, a surgical approach would have led to the loss of permanent premolar tooth buds, with a high-risk of nerve injury during cystic enucleation, considering the proximity of the lesion to the mandibular nerve (as seen on preoperative panoramic radiography). We used an efficient and evidence-based atraumatic technique to treat these large cysts. It consisted of marsupialisation to create a draining channel to relieve the intracystic pressure, followed by a thorough rinsing with saline. Drainage was maintained with a custom-made, modified Hawley plate, which also played the role of a space maintainer, prevented food impaction, and allowed access for regular cleansing. Few papers have reported on the use of such removable devices in the treatment of cysts. In fact, some authors have advocated the use of modified, removable, partial dentures in the treatment of such lesions. Our modified Hawley plate had the advantage of being more stable than a removable denture during eating. It allowed the erupting teeth to grow into place, and could have been easily adapted to the minor movements of orthodontic treatment. No evidence of recurrence was noted on follow-up radiography after marsupialisation. These results were in accordance with previous publications, which have showed that recurrence is rare after total removal of the lesion, or when a tooth erupts after marsupialisation.6 In conclusion, marsupialisation using a modified Hawley plate is an effective atraumatic treatment of dentigerous cysts in young patients.
Conflict of interest We have no conflicts of interests.
Please cite this article in press as: J. Nohra, A.R. Kassir, H. Akel, et al.. Treatment of dentigerous cysts with a modified Hawley plate in children: report of two cases with radiographic results. Br J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.bjoms.2019.09.019
YBJOM-5802; No. of Pages 3
ARTICLE IN PRESS
J. Nohra, A.R. Kassir, H. Akel et al. / British Journal of Oral and Maxillofacial Surgery xxx (2019) xxx–xxx
Ethics statement/confirmation of patients’ permission Ethics are not required for this report. The patients’ permission was obtained from their guardians.
Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.bjoms. 2019.09.019.
3
2. Chiapasco M, Rossi A, Motta JJ, et al. Spontaneous bone regeneration after enucleation of large mandibular cysts: a radiographic computed analysis of 27 consecutive cases. J Oral Maxillofac Surg 2000;58:942–9. 3. Irvine GH, Bowerman JE. Mandibular keratocysts: surgical management. Br J Oral Maxillofac Surg 1985;23:204–9. 4. Ziccardi VB, Eggleston TI, Schneider RE. Using fenestration technique to treat a large dentigerous cyst. J Am Dent Assoc 1997;128:201–5. 5. Ustuner E, Fitoz S, Atasoy C, et al. Bilateral maxillary dentigerous cysts: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:632–5. 6. Koca H, Esin A, Aycan K. Outcome of dentigerous cysts treated with marsupialization. J Clin Pediatr Dent 2009;34:165–8.
References 1. Asián-González E, Pereira-Maestre M, Conde-Fernández D, et al. Dentigerous cyst associated with a formocresol pulpotomized deciduous molar. J Endod 2007;33:488–92.
Please cite this article in press as: J. Nohra, A.R. Kassir, H. Akel, et al.. Treatment of dentigerous cysts with a modified Hawley plate in children: report of two cases with radiographic results. Br J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.bjoms.2019.09.019
YBJOM-5802; No. of Pages 3
Available online at www.sciencedirect.com
ScienceDirect British Journal of Oral and Maxillofacial Surgery xxx (2019) xxx–xxx
Short communication
Treatment of dentigerous cysts with a modified Hawley plate in children: report of two cases with radiographic results J. Nohra a,∗ , A.R. Kassir a , H. Akel b , M. Dagher a a b
Periodontology Department, Faculty of Dental Medicine, Saint-Joseph University of Beirut, Lebanon Department of Esthetic and Prosthodontics, Faculty of Dental Medicine, Saint-Joseph University of Beirut, Lebanon
Accepted 20 September 2019
Abstract Dentigerous cysts in young adults may compromise the natural evolution of the dentition and can be treated surgically or non-surgically. We report the minimally-invasive treatment of dentigerous cysts in two young patients using a modified Hawley plate to avoid traumatic injury to anatomical structures, with up to four years’ follow up. © 2019 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: odontogenic cyst; pediatric patient; non-surgical treatment; marsupialization
Introduction Dentigerous cysts are common in young adults. They are the most common odontogenic cysts, are often related to immature, non-vital, deciduous teeth, and are usually associated with the crowns of unerupted teeth.1 If left undetected or untreated, they can spread, engulf and jeopardise contiguous teeth, and may lead to extensive destruction of bone with possible fractures in extreme cases. Enucleation with complete removal (without rupture of the membrane) is usually indicated for small cysts, though it is considered to be a traumatic approach that often leads to the loss of communicating teeth.2,3 Marsupialisation is indicated for larger cysts, which usually engulf a number of teeth buds, particularly in young patients.
∗ Corresponding author at: Periodontology Department, Faculty of Dental Medicine, Saint-Joseph University, 17-5208, Mar Mikhaël Beyrouth, 11042020, Beirut, Lebanon. Fax: +9611322506. E-mail address: [email protected] (J. Nohra).
We report the successful treatment of two patients with dentigerous cysts with a non-surgical approach that used a modified Hawley plate as a marsupialisation device.
Case report Case 1 A healthy 11-year-old girl was referred because of an abnormality seen on a plain radiograph. Clinically, the lower right deciduous second molar presented with an ill-adapted amalgam with buccal bony expansion. A unilocular radiolucency below tooth number 85 extended mesially, displaced tooth number 45, and shifted the mental nerve apically (Fig. 1). Under local anaesthesia, we extracted the right, primary, mandibular second molar atraumatically, and rinsed the site abundantly with saline. A modified Hawley plate, which had been made by the treating orthodontist, was inserted as a space maintainer and means of marsupialisation (Fig. 2 and Supplemental Fig. 2, online only). She was instructed to keep
https://doi.org/10.1016/j.bjoms.2019.09.019 0266-4356/© 2019 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: J. Nohra, A.R. Kassir, H. Akel, et al.. Treatment of dentigerous cysts with a modified Hawley plate in children: report of two cases with radiographic results. Br J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.bjoms.2019.09.019
YBJOM-5802; No. of Pages 3
2
ARTICLE IN PRESS
J. Nohra, A.R. Kassir, H. Akel et al. / British Journal of Oral and Maxillofacial Surgery xxx (2019) xxx–xxx
Case 2
Fig. 1. Initial panoramic radiograph showing the cystic lesion on the lower right side, implicating the bud of tooth # 45, and displacing the mental nerve.
A healthy 10-year-old boy presented with a swelling on the lower left side of his mandible. We restored the deciduous lower right second molar with a prefabricated metal crown, which included a volumetric increase of the buccal cortical plate. Radiographic examination showed a well-defined radiolucency that engulfed the mesial root of the first permanent erupted molar and the bud of the second premolar. We treated him using the same protocol as the previous patient. The 18-month follow-up panoramic radiograph showed normal eruption of the second lower right premolar and confirmed complete bony healing. The evolution of the treatment is shown in Supplemental Figures 4-6 (online only).
Discussion
Fig. 2. The modified Hawley plate. Note the protruding acrylic resin used for marsupialisation.
Fig. 3. Four-year panoramic view of the patient after treatment showing complete radiographic healing of the bone.
the appliance on even during meals and to rinse the site profusely with saline four times a day. She was seen weekly for 12 weeks, and the protruding part of the device was progressively trimmed. At eight months, panoramic radiography showed complete healing of the bone and a normal path of eruption (Supplemental Fig. 2, online only). The fouryear follow-up panoramic radiograph showed stable results (Fig. 3).
Dentigerous cysts usually occur between the ages of 1020 years,4 predominantly in the posterior mandible.5 Both patients fell into this category, and in both, a surgical approach would have led to the loss of permanent premolar tooth buds, with a high-risk of nerve injury during cystic enucleation, considering the proximity of the lesion to the mandibular nerve (as seen on preoperative panoramic radiography). We used an efficient and evidence-based atraumatic technique to treat these large cysts. It consisted of marsupialisation to create a draining channel to relieve the intracystic pressure, followed by a thorough rinsing with saline. Drainage was maintained with a custom-made, modified Hawley plate, which also played the role of a space maintainer, prevented food impaction, and allowed access for regular cleansing. Few papers have reported on the use of such removable devices in the treatment of cysts. In fact, some authors have advocated the use of modified, removable, partial dentures in the treatment of such lesions. Our modified Hawley plate had the advantage of being more stable than a removable denture during eating. It allowed the erupting teeth to grow into place, and could have been easily adapted to the minor movements of orthodontic treatment. No evidence of recurrence was noted on follow-up radiography after marsupialisation. These results were in accordance with previous publications, which have showed that recurrence is rare after total removal of the lesion, or when a tooth erupts after marsupialisation.6 In conclusion, marsupialisation using a modified Hawley plate is an effective atraumatic treatment of dentigerous cysts in young patients.
Conflict of interest We have no conflicts of interests.
Please cite this article in press as: J. Nohra, A.R. Kassir, H. Akel, et al.. Treatment of dentigerous cysts with a modified Hawley plate in children: report of two cases with radiographic results. Br J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.bjoms.2019.09.019
YBJOM-5802; No. of Pages 3
ARTICLE IN PRESS
J. Nohra, A.R. Kassir, H. Akel et al. / British Journal of Oral and Maxillofacial Surgery xxx (2019) xxx–xxx
Ethics statement/confirmation of patients’ permission Ethics are not required for this report. The patients’ permission was obtained from their guardians.
Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.bjoms. 2019.09.019.
3
2. Chiapasco M, Rossi A, Motta JJ, et al. Spontaneous bone regeneration after enucleation of large mandibular cysts: a radiographic computed analysis of 27 consecutive cases. J Oral Maxillofac Surg 2000;58:942–9. 3. Irvine GH, Bowerman JE. Mandibular keratocysts: surgical management. Br J Oral Maxillofac Surg 1985;23:204–9. 4. Ziccardi VB, Eggleston TI, Schneider RE. Using fenestration technique to treat a large dentigerous cyst. J Am Dent Assoc 1997;128:201–5. 5. Ustuner E, Fitoz S, Atasoy C, et al. Bilateral maxillary dentigerous cysts: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:632–5. 6. Koca H, Esin A, Aycan K. Outcome of dentigerous cysts treated with marsupialization. J Clin Pediatr Dent 2009;34:165–8.
References 1. Asián-González E, Pereira-Maestre M, Conde-Fernández D, et al. Dentigerous cyst associated with a formocresol pulpotomized deciduous molar. J Endod 2007;33:488–92.
Please cite this article in press as: J. Nohra, A.R. Kassir, H. Akel, et al.. Treatment of dentigerous cysts with a modified Hawley plate in children: report of two cases with radiographic results. Br J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.bjoms.2019.09.019