The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014
8. Shah JP, Haribhaki V, Loree TR, et al. Complications of the pectoralis major myocutaneous flap in head and neck reconstruction. Am J Surg 1990;160:352Y355 9. Mehrof AI, Rosenstock A, Neifeld JP, et al. The pectoralis major myocutaneous flap in head and neck reconstruction. Am J Surg 1983;146:478Y480 10. Baek SM, Lawson W, Biller HF. An analysis of 133 pectoralis major myocutaneous flaps. Plast Reconstr Surg 1982;69:460Y465
A Clinicoradiographic and Pathological Study of Pericoronal Follicles Associated to Mandibular Third Molars Fa´bio Wildson Gurgel Costa, DDS, PhD,* Thales Salles Angelim Viana, DDS,Þ Galyle´ia Meneses Cavalcante, DDS,Þ Paulo Goberlaˆnio de Barros Silva, DDS,Þ Roberta Barroso Cavalcante, DDS, PhD,þ Alexandre Simo˜es Nogueira, DDS, MSc,§ Karuza Maria Alves Pereira, DDS, PhD,§ Background: Third molar surgery is considered the most frequently performed procedure in oral surgery. Although there are some indications for the removal of this tooth, such as the possibility of cystic degeneration or a tumor of the adjacent pericoronal follicle, there is no consensus in the literature about their prophylactic removal. Objectives: The aims of this study were to investigate the pathological alterations related to mandibular third molar dental follicles and to perform a narrative literature review. Methods: A prospective clinical, radiographic, and histopathologic study was conducted with pericoronal follicles of third molars. After histopathologic evaluation and establishment of diagnosis, 2 groups were defined: G1 (pericoronal tissues with pathological alterations based on histopathologic analysis) and G2 (pericoronal tissues without pathological alterations based on histopathologic analysis). In addition, a systematic review of the literature was performed. Results: One hundred thirteen specimens were analyzed. G1 was the most prevalent (P = 0.0004). Lesions were found in patients between 20 and 25 years of age (P < 0.004). The most prevalent histological diagnosis was the paradental cyst (47.7%; P < 0.0001). The narrative literature review showed that the majority of cases were mainly dentigerous cysts (P < 0.05). Conclusions: The mandibular third molars in young adults showed a direct relationship with age and a statistical propensity for the development of these cystic alterations, notably paradental cysts. From the *Oral Radiology Department and †Stomatology Department, School of Dentistry, Federal University of Ceara´; and ‡Oral Pathology Department, School of Dentistry, Fortaleza University, Fortaleza; and §Stomatology and Oral Pathology Department, School of Dentistry, Federal University of Ceara´, Campus Sobral, Ceara´, Brazil. Received November 30, 2013. Accepted for publication January 6, 2014. Address correspondence and reprint requests to Fa´bio Wildson Gurgel Costa, DDS, PhD, Rua Joa˜o Sorongo, 1016, apto. 205, Jardim Ame´rica; CEP 60416-000, Fortaleza-Ce, Brazil; E-mail: [email protected]
No funding was received for this study. The authors report no conlficts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000712
Brief Clinical Studies
Key Words: Third molar, pathology, pericoronal follicles, paradental cysts
hird molar (3M) surgery is considered the most frequently performed procedure in oral surgery.1,2 Although there are some indications for the removal of this tooth, such as the possibility of cystic degeneration or a tumor of the adjacent pericoronal follicle, there is no consensus in the literature about their prophylactic removal.3 Thus, this research aimed to conduct a prospective clinicoradiographic and pathological study of pericoronal follicles associated to mandibular 3Ms in a Brazilian population and to perform a narrative literature review to compare the results of this study with previously published data.
METHODS AND MATERIALS A prospective study was conducted in which clinical, radiographic, and histopathologic data were collected from patients who presented at the dental specialties clinic ‘‘Centro de Especialidades Odontolo´gicas Sanitarista Se´rgio Arouca’’ in Sobral, Brazil, for the surgical removal of 3Ms between March 2007 and August 2011. Patients who had undergone at least 1 surgery for removal of mandibular 3Ms were included in the current study. Patients were excluded from the study when their reports referred to pathologies associated with other teeth or when the information contained in the reports was incomplete. This study was approved by the Ethics Committee of the Universidade Vale do Acarau´, Sobral, Brazil (protocol 1018/11). All patients sent the term of consent signed. The data were analyzed according to sex, age, histopathologic type, degree of dental eruption (erupted, partially erupted, and nonerupted), angulation, and radiographic and macroscopic size. A researcher who was blind to the group to which the analyzed radiograph belonged measured the radiographic size of the radiolucent area around the 3Ms. For this purpose, measurement was standardized as follows: the pericoronal radiolucency was measured by means of an endodontic millimeter ruler (Golgran, Brası´lia, Federal District, Brazil) on a negatoscope, tracing a straight line parallel to the occlusal surface of the tooth along its longest mesiodistal axis on the crown. The diameter of the radiolucency was measured by the following formula: longest diameter of radiolucency = longest diameter between the mesial face of the tooth and the end of the radiolucent area j longest coronal diameter between the mesial and distal faces of the tooth (Fig. 1). The macroscopic size of the tissue was collected according to its largest size as shown on the anatomopathological report. The histopathologic diagnosis was established in accordance with the most recent World Health Organization criteria.4,5 The histopathologic characteristics of the paradental (pathological cavity lined by a hyperplastic epithelium and the presence of intense chronic inflammation) and dentigerous cysts (thin fibrous cystic wall lined by 2- to 3-layer-thick stratified nonkeratinizing squamous epithelium and the presence of scarce inflammatory infiltration in the cellular connective tissue) are illustrated in Figures 2 and 3, respectively.4,5 After histopathologic evaluation and establishment of diagnosis, 2 groups were defined: G1 (pericoronal tissues with pathological alterations based on histopathologic analysis) and G2 (pericoronal tissues without pathological alterations based on histopathologic analysis). In addition, a narrative literature review was conducted to compare the presented sample with previously published studies. The search strategy was applied in the PubMed, MEDLINE and LILACS databases with the keywords ‘‘third molar,’’ ‘‘dental follicle,’’ and ‘‘pathology.’’ The search resulted in an initial sample of 221 scientific articles. After an initial refinement, only 34 articles remained;
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Brief Clinical Studies
FIGURE 1. A, Radiographic appearance of a pericoronal radiolucency. B, Schematic image of the methodology for assessing the size of the radiolucency of the processes associated with lower 3Ms.
187 articles were excluded after reading the titles because they did not coincide with the subject matter. After further filtering, 23 articles were excluded because they did not meet the inclusion criteria; thus, only 11 articles were selected for detailed analysis. The eligibility criteria included articles that consisted of a histopathologic investigation and were written in English, Portuguese, or Spanish in the period from 1999 to 2012. Articles related to other teeth, literature reviews, case reports, editorials, and radiographic research without histopathologic proof were excluded. The data were analyzed with the aid of the BioEstat 5.0 program (Institute for Sustainable Development Mamiraua´, Ministry of Science, Brazil), and the nominal qualitative variables were expressed as absolute frequencies and were analyzed using the W2 test or Fisher exact test. The prevalence rates for each study were individually compared with those of the current study by calculating the estimated difference in proportions. In all the cases, the probability > was established at 5%, and P < 0.05 (2 tailed) was considered to be statistically significant.
RESULTS General Results The final sample was composed of 113 pericoronal follicles surgically removed from 104 patients (ratio of number of surgical specimens: number of patients = 1.09:1.00). Of these, 42 were pertained to males (37.1%), versus 71 (62.9%) from females (P = 0.0603). The ages ranged from 13 to 71 years, with a mean age of 24 years. The most prevalent age range was between 20 and 25 years of age (P = 0.0017). With regard to the degree of impaction, 79 teeth were partially erupted, and 20 were nonerupted (P < 0.0001). Radiographically, the sizes ranged between 0.50 and 45.00 mm (mean, 2.97 mm). G1 was the most prevalent (n = 83; 73.4%) between the groups, presenting a statistically significant difference in comparison with G2 (P = 0.0004; Table 1).
G1VThird Molars With Associated Pathological Lesions This group consisted of 83 specimens from 78 patients, of which 59% pertained to female, with an age range between 13 and 71 years (mean, 24.66 years) (Table 1). The peak age in this group was between 20 and 25 years, with 49 specimens (59%) identified. The most frequently identified pathological alteration was the paradental
FIGURE 2. Paradental cyst. Photomicrograph showing a pathological cavity lined by a hyperplastic epithelium and the presence of intense chronic inflammation (hematoxyln-eosin stain, original magnification 200).
& Volume 25, Number 3, May 2014
FIGURE 3. Dentigerous cyst. Photomicrograph showing a thin fibrous cystic wall lined by 2- to 3-layer-thick stratified nonkeratinizing squamous epithelium and the presence of scarce inflammatory infiltration in the cellular connective tissue (hematoxyln-eosin stain, original magnification 400).
cyst (n = 55; 66.2%), followed by the dentigerous cyst (n = 21; 25.3%). Seven samples (8.5%) were not conclusively diagnosed. The majority of the teeth were partially erupted (P < 0.0001; Table 1). Radiographically, the pericoronal radiolucent areas ranged between 0.50 and 45.00 mm in diameter (mean, 3.23 mm). The radiographic examination revealed lesions that were smaller than 2 mm (n = 25; 30.1%), with no statistical significance. Macroscopically, the surgical tissues ranged between 0.40 and 3.50 cm (mean, 1.49 cm). The majority of the tissues were of a macroscopic size smaller than 2 cm (n = 55; 66.2%) (Table 2).
G2VThird Molars Without Associated Pathological Lesions This group was composed of 30 specimens from 26 patients, of which 22 pertained to female (mean age, 22.1 years) and 8 were male (mean age, 23.6 years). The patients’ ages ranged from 13 to 38 years (mean, 22.50 years). With respect to the radiographic position, 13 teeth (43.3%) were nonerupted, and 10 teeth (33.3%) partially erupted. Radiographically, the size of the dental follicle space ranged from 0.50 to 7.00 mm (mean, 2.21 mm). Ten teeth were of less than 2.00 mm (n = 10; 33.3%). Macroscopically, the surgical tissues ranged between 0.50 and 2.30 cm (mean, 1.38 cm). The majority of the tissues were of a macroscopic size smaller than 2.00 cm (n = 22; 73.3%). There was no statistically significant difference in the comparison with G1 (P= 0.8140) (Table 2).
Literature Review Initially, a total of 3675 specimens were obtained from 8344 patients (Table 3). Because of the absence of data in 2 studies,6,7 TABLE 1. Distribution of the Groups According to Sex, Age Range (in Years), and Degree of Dental Eruption (n = 113)
Group 1 (n = 83)
Group 2 (n = 30)
34 (40.96%) 49 (59.04%)
8 (26.67%) 22 (73.33%)
42 (37.17%) 71 (62.83%)
11 (13.25%) 49 (59.04%) 23 (27.71%)
9 (30%) 14 (46.67%) 7 (23.33%)
20 (17.70%) 63 (55.75%) 30 (26.55%)
2 (2.41%) 69 (83.13%) 7 (8.43%) 5 (6.03%)
2 10 13 5