dentigerous cysts ( dc ) are benign odontogenic lesions caused by an alteration of reduced enamel epithelium which results in fluid accumulation either between the reduced enamel epithelium and the crown of an unerupted / impacted tooth or within the enamel organ itself . dcs are usually asymptomatic , and they may be detected incidentally via routine radiographic examination or when they are large enough ( > 2  cm in diameter ) to cause facial asymmetry [ 13 ] . clinical signs suggestive of a dc include a retained deciduous tooth , delayed eruption of a permanent tooth , and painless swelling of the involved area . in radiographs , the dc appears as a well - defined unilocular radiolucency associated with the crown of an unerupted tooth . often the radiolucent area surrounds the crown , but sometimes it lies mainly or entirely to one side [ 4 , 5 ] . the first theory suggests that dcs are developmental in origin and occur in mature teeth usually as a result of impaction . these cysts usually occur in the late second and third decades , predominantly involving mandibular third molars . the second theory advocates that dcs are inflammatory and occur in immature teeth as a result of inflammation from a nonvital deciduous tooth or another source spreading to involve the tooth follicle . these are diagnosed in the first and early part of second decade , predominantly involving mandibular premolars . it is important to emphasize that dcs in children might show a rapid and painless expansion and may result in fractures and deformation of facial bone structures . the aim of the present paper is to describe clinical , radiological , and histopathological findings of four additional cases with dcs treated by conservative surgical techniques . to our knowledge , this study constitutes the first reported case of dc in which affected permanent tooth was intentionally replanted to its place after marsupialization . four boys , aged between 7 and 9 years , were referred to clinics in the department of pediatric dentistry at istanbul university with the chief complaints of intraoral alveolar swelling or facial asymmetry on the affected area . the patients were evaluated by a comprehensive clinical and radiologic examination , including panoramic radiography and cone beam computed tomography ( cbct ) . clinical and radiographic images of these cases are shown in figures 1 , 2 , 3 , and 4 . all of the cases were treated by extraction of the deciduous tooth around the cyst and marsupialization of the cyst to allow eruption of the permanent tooth . in all cases , a biopsy tissue sample was taken from the access window of marsupialization for the histopathological examination , and then a silicon tube was installed to drain the intracystic pressure . the histopathologic examination of the lesions confirmed the diagnostic hypothesis of a dentigerous cyst with inflammatory origin . in our study , the histopathologic features of all four cases were similar . figures 5 and 6 show representative pictures of the cysts , all of which were inflamed . the cysts were lined by stratified squamous epithelium which demonstrated hyperplastic rete ridges , particularly in high inflamed areas . the fibrous wall of the cysts contained an inflammatory infiltrate containing lymphocytes variably intermixed with plasma cells and eosinophils . permanent teeth displaced by the dcs in three cases erupted in proper position spontaneously within a one - year period . the other case with a horizontally displaced permanent premolar did not have a chance to erupt spontaneously ; thus intentional replantation was chosen as the treatment . after nine months of healing of the cyst cavity , the tooth was extracted and replaced in its proper place in the arch by surgery in a position where the alveolar bone support is highest . therefore , the crown of the replanted tooth was in a slightly vestibular position at the end of surgery . a follow - up visit at twenty - eight months showed complete healing of the surrounding bone and the tooth was asymptomatic . dcs are the third most common odontogenic cysts , after radicular cysts and odontogenic keratocyst , and account for approximately 10.39% of all odontogenic cysts . swelling can be experienced if the dc grows too large or lies in a sensitive area . evaluated thirty - five children diagnosed with dc and determined that swelling was the main complaint in 70% of the children , while 5% experienced pain and 25% had no symptoms . in the present cases , the main complaint of two patients ( cases 2 and 4 ) was facial swelling , while the main complaint of case 1 was a hard swelling described around the buccal sulcus of the premolar region . case 3 was referred to our faculty when no regression could be provided with a one - week i m antibiotic treatment on swelling . considering that the size of a normal follicular space in radiographs is 3 to 4  mm in diameter , a dc can be suspected when a follicular space measuring more than 5  mm is observed [ 9 , 10 ] . conventional panoramic and periapical radiographs are sufficient to detect the lesion , but they may fail to delineate the full extent of the lesion . it is therefore important to use more advanced imaging techniques , such as 3d ct , especially in extensive lesions . ct imaging provides more accurate information about the lesion 's size , its relationship to adjacent anatomical structures , and the position of the underlying permanent tooth . it is emphasized that an additional ct scan should be preferred for large lesions extending to the nasal cavity or orbital or pterygomaxillary space . in the present study , an additional ct scan was performed only in cases 2 and 4 . a ct scan in case 2 was required for the complete delineation of the cystic lesion considering its close proximity to the maxillary sinus and the horizontal position of the involved premolar . in case 4 , the cystic lesion was so extensive and close to the base of the mandible that the ct scan was helpful in assessing the precise extent of the lesion . in all cases , panoramic radiographs were preferred for the periodic follow - up visits . radicular cysts described in association with the pulpotomized primary molars seem to show similar clinical features with inflammatory dentigerous cysts . several differences were reported between the radiological features of radicular cysts and dentigerous cysts by various reports [ 1113 ] . basically , the pericoronal space of the underlying permanent tooth in radicular cysts appears normal , usually with a total or partially distinct cortical layer of bone . dcs , on the other hand , generally have no distinct boundaries between the roots of primary tooth and the crown of the underlying permanent teeth . even though these differences are not adequate for a definitive diagnosis , they are still important for a provisional diagnosis . shaw et al . noted that distinguishing inflammatory dentigerous and radicular cysts on histologic grounds is also difficult . therefore , it is important to examine clinical , radiological , and histological findings together to make a definite diagnosis . because dcs have the potential to form an ameloblastoma , an accurate diagnosis and its differentiation from a radicular cyst are of paramount importance . in the present study , a provisional diagnosis of dc was made for all of the cases , based on clinical and radiographical examination . histopathological examination confirmed the diagnosis and revealed that all of the cases were inflammatory in origin . enucleation involves the complete removal of all tissues involved with the cyst , including removal of the unerupted tooth . marsupialization or decompression is a technique that attempts to relieve intracystic pressure through the creation of an accessory cavity . the treatment approach for children with dcs should be less invasive to preserve affected permanent teeth , as teeth with open apices have great eruptive potential . although the cystic lesions had changed the position of the underlying permanent teeth in varying degrees , all teeth except case 2 returned to a satisfactory position and erupted spontaneously after treatment . in case 2 , therefore , after maintaining the complete healing of the cystic lesion and considerable amount of bone was formed at about nine months , the tooth was replanted to its correct position by another surgical operation . the major disadvantage of marsupialization is pathologic tissue left in situ without a thorough histological examination , because of the possibility that a more aggressive lesion may occur in the residual tissue . however , recurrence of dc is rare , especially after complete removal of the cyst or tooth eruption . in the present cases , conservative treatment led to a high quality outcome . all teeth maintained their vitality and no recurrence was observed at the follow - up periods . conservative treatment is a favorable treatment modality for dcs in growing children and adolescents . considering that the regeneration capacity of the bony structures in children is greater than in adults and the teeth with open apices have greater eruptive potential , efforts should be made to allow the involved tooth to erupt spontaneously . intentional replantation could also be employed in teeth which have a great strategic value for maintaining the balanced occlusion .
dentigerous cysts ( dcs ) are benign odontogenic cysts that are associated with the crowns of permanent teeth . 
 the purpose of this study is to describe the management of dcs in four children . 
 four boys aged between 7 and 9 years were referred to our clinics with the complaints of intraoral alveolar swelling or facial asymmetry on the affected area . 
 the panoramic radiographies showed large , well - defined radiolucent lesions associated with the deciduous teeth and displaced tooth buds . 
 the treatment consisted of the extraction of the involved deciduous tooth and marsupialization of the cyst to allow eruption of the permanent tooth . 
 permanent teeth displaced by the dcs in three cases erupted spontaneously within one - year period . 
 the case with horizontally displaced permanent tooth was managed by replantation . 
 this is the first time that underlying permanent tooth in a dc case was intentionally replanted .