dentistry journal Case Report Uprighting an Impacted Permanent Mandibular First Molar Associated with a Dentigerous Cyst and a Missing Second Mandibular Molar—A Case Report Konstantina Tsironi 1,* , Emmanouil Inglezos 1, Emmanouil Vardas 2 and Anastasia Mitsea 3 1 Posidonos 14, Imia square, Voula, 16673 Athens, Greece 2 Clinic of Hospital Dentistry, Dental School, National and Kapodistrian University of Athens, Thivon 2 Goudi, 11527 Athens, Greece 3 Department of Oral Diagnosis and Radiology, Dental School, National and Kapodistrian University of Athens, Thivon 2 Goudi, 11527 Athens, Greece * Correspondence: [email protected]; Tel.: +30-698-682-7064 Received: 3 April 2019; Accepted: 21 May 2019; Published: 27 June 2019 Abstract: The purpose of this paper is to present a case of an impacted mandibular first molar associated with a dentigerous cyst and a missing mandibular second molar in an 11-year-old girl that was treated with combined surgical and orthodontic procedures. After clinical and radiographic evaluation, marsupialization of the cyst was decided, and a molar attachment was bonded on the buccal side of the impacted molar as a part of a full orthodontic treatment with fixed appliances. After 18 months of orthodontic traction, the molar was moved to a more advantageous position, and new bone apposition was observed on the site of the cystic lesion. Histological examination confirmed a dentigerous cyst. The molar was left to erupt spontaneously for 14 more months. A functional occlusion was finally achieved. An interdisciplinary approach proved to be an effective modality in treating a large dentigerous cyst associated with a deeply impacted first mandibular molar, presenting many advantages, such as new bone apposition and patient comfort. Keywords: first molar uprighting; impacted molar; dentigerous cyst; unerupted tooth; missing second mandibular molar 1. Introduction Tooth impaction can be defined as tooth retention due to an obstacle in the eruption path or—less commonly—due to an ectopic position of the tooth germ [1]. Tooth impaction is relatively common (prevalence of 17%) [2], third molars being the most commonly affected teeth, followed by maxillary canines, mandibular premolars, and mandibular canines. The prevalence rate of impaction for the mandibular second molar ranges from 0.06 to 0.3%, and for the mandibular first molar, the prevalence described is <0.01% [3]. Impaction of the first molar is a serious problem that needs to be addressed in order to achieve functional occlusion and facial harmony. In cases of non-treatment, it can cause a decrease in the vertical dimension of the lower face, malocclusion, extrusion of the antagonist, root resorption in the adjacent teeth, or formation of a dentigerous cyst [4,5]. Dentigerous cysts are odontogenic cysts that originate by separation of the follicle from around the crown of an unerupted tooth [6]. Generally, they are associated with the crowns of impacted or unerupted permanent teeth or, less frequently, with an odontoma, a developing tooth, or a deciduous tooth [7,8]. The incidence of dentigerous cysts in the general population has been estimated at 1.44 cysts for every 100 unerupted teeth [9], comprising the second most common (14 to 24%) of all odontogenic cysts [10,11]. Most often, dentigerous cysts present no clinical symptoms and are detected during routine radiographic examination. In some cases, gum swelling or sensitivity, Dent. J. 2019, 7, 63; doi:10.3390/dj7030063 www.mdpi.com/journal/dentistry Dent. J. 2019, 7, x FOR PEER REVIEW 2 of 10 Dent. J. 2019, 7, 63 2 of 10 detected during routine radiographic examination. In some cases, gum swelling or sensitivity, tooth mobility, and displacement of adjacent teeth may be observed if the cyst reaches large dimensions tooth(>2 cm mobility, in diameter) and displacement or if it gets infected of adjacent [6,12]. teeth Radiographically, may be observed dentigerous if the cyst reaches cysts are large characterized dimensions (by>2 a cm symmetric, in diameter) well-circumscribed or if it gets infected radiolucent [6,12]. Radiographically, lesion, most often dentigerous unilocular, surrounding cysts are characterized the crown byof an a symmetric,unerupted tooth well-circumscribed [12,13]. Differential radiolucent diagnosi lesion,s from most other often cysts, unilocular, such as radicular surrounding cysts and the crownodontogenic of an keratocysts, unerupted toothor from [12 tumors,,13]. Di suchfferential as ameloblastoma, diagnosis from calcifyi otherng cysts, epithelial such odontogenic as radicular cyststumor, and and odontogenic odontogenic keratocysts, fibroma, is necessary or from tumors, through such histopathologic as ameloblastoma, evaluation calcifying [14]. Dentigerous epithelial odontogeniccysts are generally tumor, treated and odontogenic surgically either fibroma, by enucleation, is necessary marsupialization, through histopathologic or by decompression evaluation [14 of]. Dentigerousthe cyst via cystsfenestration are generally [15–17]. treated This surgicallycase report either describes by enucleation, a conservative marsupialization, surgical approach or by decompressioncombined with oforthodontic the cyst via treatment fenestration of [15an– 17impacted]. This case first report mandibular describes molar a conservative associated surgicalwith a approachdentigerous combined cyst in an with adolescent. orthodontic treatment of an impacted first mandibular molar associated with a dentigerous cyst in an adolescent. 2. Case Presentation 2. Case Presentation An 11-year old female came to the clinic after her parents complained of missing lower left teeth. No painAn 11-yearor previous old female discomfort came was to the reported. clinic after The her overall parents patient’s complained dental of and missing physical lower health left teeth. was Nogood pain with or previousnon-specific discomfort general wasmedical reported. history The an overalld no contra-indication patient’s dental and to dental physical treatment. health was A goodsigned with informed non-specific consent general from medicalthe patient’s history mother and no was contra-indication obtained before to dentalthe patient treatment. participated A signed in informedthe study. consent from the patient’s mother was obtained before the patient participated in the study. Extraoral examination revealed a symmetric face with no deficitdeficit in the lower left part of the the face. face. Intraoral examinationexamination revealed revealed a a Class Class II II incisor incisor relationship relationship and and a Class a Class II molarII molar relationship relationship from from the rightthe right side side in a latein a mixedlate mixed dentition. dentition. At the At left the side, left theside, first the mandibular first mandibular molar wasmolar clinically was clinically absent, andabsent, the and overlying the overlying mucosa wasmucosa normal was in normal color and in color texture. and The texture. adjacent The deciduous adjacent deciduous second molar second had amolar large had amalgam a large restoration amalgam restoration with no signs with of no secondary signs of caries.secondary caries. The panoramicpanoramic radiographic radiographic examination examination (PanRad) (PanRad) revealed revealed the presencethe presence of six permanentof six permanent molars inmolars the upper in the jawupper and jaw five and permanent five permanent molars molars in the lowerin the jawlower (Figure jaw (Figure1). From 1). the From size the of size the teeth,of the theteeth, stage the of stage the root of formation,the root formation, the location the of thelocati teethon buds,of the and teeth the buds, angulation and the of the angulation impacted of molar, the itimpacted was assumed molar, that it was the impactedassumed that tooth the was impacted the first tooth mandibular was the molar, first mandibular and the adjacent molar, tooth and bud the wasadjacent the mandibular tooth bud thirdwas the molar. mandibular A well-circumscribed third molar. unilocularA well-circumscribed radiolucent lesion unilocular in the radiolucent body of the mandiblelesion in the was body noticed, of the associated mandible with was the noticed, crown a ofssociated the vertically with the impacted crown mandibularof the vertically left first impacted molar. Themandibular roots of left the impactedfirst molar. molar The roots were of completely the impacted developed molar were with completely closed apexes. developed The cephalometric with closed X-rayapexes. confirmed The cephalometric a skeletal Class X-ray II malocclusionconfirmed a skeletal (Figure2 Class). The II clinical malocclusion diagnosis (Figure was dentigerous 2). The clinical cyst associateddiagnosis was with dentigerous the impacted cyst molar. associated with the impacted molar. Figure 1. Pretreatment panoramic radiograph showing an impacted mandibular left molar associated with aa rather rather large, large, well well circumscribed, circumscribed, unilocular unilocula radiolucentr radiolucent lesion. Thelesion. root The is almost root fullyis almost developed. fully developed. Dent. J. 2019, 7, 63 3 of 10 Dent.Dent. J. J. 2019 2019, 7, ,7 x, xFOR FOR PEER PEER REVIEW REVIEW 3 3of of 10 10 FigureFigure 2. 2. Pretreatment PretreatmentPretreatment cephalometric cephalometric radiograph radiograph showing showing a askeletal skeletal Class Class II II profile. profile. profile. TheThe main main objectives objectives objectives of of of the the the treatment treatment treatment plan plan plan were