The Journal of Craniofacial Surgery

Correspondence

Complete Eruption of a Deeply Impacted Tooth in a Recurrent Keratocystic Odontogenic Tumor With Orthodontic Occlusal Alignment To the Editor: Keratocystic odontogenic tumor (KCOT) is considered to be a benign odontogenic tumor with locally aggressive and infiltrative behavior. Decompression for KCOT is a useful and conservative technique, especially in pediatric patients.1 We report a case involving the recurrence of a KCOT during the decompression phase where a daughter cyst developed in a pediatric patient. A 10-year-old girl was referred to our clinic, because of painless swelling on the lower jaw. Intraoral examination showed a buccal bony expansion over the lower right first premolar and second deciduous molar, with no facial asymmetry. A panoramic radiograph exhibited a well-defined unilocular radiolucent lesion of approximately 1.5  2-cm diameter, including the right lower second premolar germ, which was displaced to the mandibular basis region (Fig. 1A). We chose decompression for management of the cystic lesion because we predicted that the impacted tooth germ would erupt. After the procedure was explained to the patient and her parents, the lower right deciduous second molar was extracted, followed by tissue biopsy via extraction socket under local anesthesia. Then, a gauze pack was inserted into the cavity window to prevent spontaneous closure. Histopathologically, the lesion was diagnosed as a KCOT (Fig. 1B). At the ninth month, daughter cysts were observed at the base of the cyst cavity. Therefore, the decompression period ended, and it was considered that the lesion had recurred (Fig. 1C). The patient was scheduled for complete elimination of the pathological lesion around the second premolar by enucleation and minimal peripheral ostectomy, as well as resection of the right mandibular first molar mesial root under general anesthesia. A second biopsy confirmed a recurrent KCOT (Fig. 1D). Six months after surgery, panoramic radiography showed evidence of new bone remodeling with no recurrence and revealed that the right lower second premolar had erupted incompletely because

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FIGURE 1. A, Panoramic radiograph reveals a large, well-delineated, unilocular lesion with displacing the tooth germ. B, Histological photograph showing a stratified squamous epithelium with underlying fibrous connective tissue and a palisaded basal cell layer, corrugated and parakeratinized at the epithelial surface (hematoxylin-eosin stain, original magnification 100). C, Panoramic view obtained in the ninth month, showing a new daughter cyst recurrence in the inferior border of the right mandible (arrows). D, Histologic appearance of second biopsy specimen after enucleation (hematoxylin-eosin stain, original magnification 100).

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FIGURE 2. A, Intraoral photograph during the space regaining process for impacted tooth eruption by orthodontic treatment. B, Postoperative intraoral image after orthodontic intervention. C, Good alignment of the right lower second premolar and bone regeneration after 24 months.

of the narrow interdental space between the first molar and premolar. Subsequently, orthodontic treatment was initiated in the mandibular arch with bonding of 0.22-inch pretorqued and preangulated MBT brackets (Equilibrium 2; Dentaurum, Ispringen, Germany) from the lower right first molar to the left molar (Fig. 2A). After a leveling stage with round wires, a 1622 stainless-steel wire was placed, and coil springs were applied between the lower right first premolar and the right first molar in order to open space to the lower right second premolar. After the space-opening process, a bracket was bonded to the mandibular right second premolar and connected with ligature wire to the archwire from a 1- to 2-mm distance. The mandibular right second premolar came to the occlusal level, and continuous archwire was applied. At the end of 24 months of follow-up, the patient was free from pathological lesions. The bone defect was observed to have healed, and the tooth within the cyst had erupted and was aligned in proper position in the dental arch with supporting orthodontic treatment (Figs. 2B, C). Clinical observations have shown that there is a close relationship between the ability of a tooth to erupt and the level of dental root formation and tooth axis angulation.2– 4 Hyomoto et al3 reported that natural eruption of impacted teeth in dentigerous cysts with treated marsupialization could be observed in teeth with less than 80 degrees of axis angulation; the actual tooth eruption rate was 72.4%. On the other hand, Qian et al5 noted that tooth eruption was achieved by a conservative approach but concluded that the angulation and eruption space were not contributing factors in preventing eruption in preadolescent patients. Another factor influencing the speed of eruption into the oral cavity is rapid new bone regeneration accompanied with reduced cyst pressure.5,6 Interestingly, although new bone formation was not as desired until the daughter cyst was observed in our case, the impacted tooth exhibited a tendency toward its correct eruption path. Concerning orthodontic requirements for unerupted teeth within cystic cavities, different options have been proposed. It is suggested that orthodontic traction with surgical exposure could be more effective than spontaneous eruption in those treated for dentigerous cyst by marsupialization.7,8 In contrast to this, it has been well documented in many cases that without orthodontic traction, spontaneous eruption can be observed after the extraction of deciduous teeth and cyst decompression.9,10 In our case, the lower right second premolar was observed to spontaneously erupt, but orthodontic alignment was necessary for complete occlusal leveling. #

2015 Mutaz B. Habal, MD

Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery



Volume 26, Number 3, May 2015

Although it dealt with only 1 case, the present report showed that decompression after enucleation might be a good option for conservative management of KCOT in growing patients. The findings of the present case emphasize that the impacted tooth in a KCOT should not be removed initially, even in the presence of recurrence during the decompression phase. Mehmet Demirkol, DDS, PhD Department of Oral and Maxillofacial Surgery Faculty of Dentistry Gaziantep University Gaziantep, Turkey [email protected] Aydin Keskinruzgar, DDS, PhD Bilal Ege, DDS, PhD Department of Oral and Maxillofacial Surgery Faculty of Dentistry Adiyaman University Adiyaman, Turkey Ridvan Oksayan, DDS, PhD Department of Orthodontics Faculty of Dentistry Gaziantep University Gaziantep, Turkey Suna Erkilic, MD, PhD Department of Pathology Faculty of Medicine Gaziantep University Gaziantep, Turkey M. Hamdi Aras, DDS, PhD Department of Oral and Maxillofacial Surgery Faculty of Dentistry Gaziantep University Gaziantep, Turkey

REFERENCES 1. Giuliani M, Grossi GB, Lajolo C, et al. Conservative management of a large odontogenic keratocyst: report of a case and review of the literature. J Oral Maxillofac Surg 2006;64:308–316 2. Fujii R, Kawakami M, Hyomoto M, et al. Panoramic findings for predicting eruption of mandibular premolars associated with dentigerous cyst after marsupialization. J Oral Maxillofac Surg 2008;66:272–276 3. Hyomoto M, Kawakami M, Inoue M, et al. Clinical conditions for eruption of maxillary canines and mandibular premolars associated with dentigerous cysts. Am J Orthod Dentofacial Orthop 2003;124:515–520 4. Kokich VG, Mathews DP. Surgical and orthodontic management of impacted teeth. Dent Clin North Am 1993;37:181–204 5. Qian WT, Ma ZG, Xie QY, et al. Marsupialization facilitates eruption of dentigerous cyst-associated mandibular premolars in preadolescent patients. J Oral Maxillofac Surg 2013;71:1825–1832 6. Miyawaki S, Hyomoto M, Tsubouchi J, et al. Eruption speed and rate of angulation change of a cyst-associated mandibular second premolar after marsupialization of a dentigerous cyst. Am J Orthod Dentofacial Orthop 1999;116:578–584 7. Martı´nez-Pe´rez D, Varela-Morales M. Conservative treatment of dentigerous cysts in children: a report of 4 cases. J Oral Maxillofac Surg 2001;59:331–333 8. Jena AK, Duggal R, Roychoudhury A, et al. Orthodontic assisted tooth eruption in a dentigerous cyst: a case report. J Clin Pediatr Dent 2004;29:33–35 #

2015 Mutaz B. Habal, MD

Correspondence

9. Delbem AC, Cunha RF, Afonso RL, et al. Dentigerous cysts in primary dentition: report of 2 cases. Pediatr Dent 2006;28:269–272 10. Berti Sde A, Pompermayer AB, Couto Souza PH, et al. Spontaneous eruption of a canine after marsupialization of an infected dentigerous cyst. Am J Orthod Dentofacial Orthop 2010;137:690–693

Nonsyndrome Multiple Supernumerary Teeth To the Editor: The supernumerary teeth appear in addition to the regular number of dental elements1,2 and may be single or multiple, unilateral or bilateral, erupted or impacted, in 1 or both jaws.3 Its occurrence is associated with patients suffering from syndromes such as cleft lip and palate,2 cleidocranial dysostosis,4 and Gardner syndrome.5 Although there are case reports in literature,2,6,7 the presence of multiple supernumerary teeth in individuals with no other associated diseases or syndromes is unusual.8 – 10 Thus, the aim of this study was to report a case of a patient with nonsyndromic multiple supernumerary teeth, emphasizing the clinical approach as a crucial aspect for a successful outcome. A 31-year old male patient was referred by the orthodontist, diagnosed with multiple hyperdontia and indication of exodontics of teeth 18, 28, 48, 38, and 14, besides 10 supernumerary teeth (Fig. 1A). A detailed interview was performed, in which the patient reported not having any disease or syndrome, as well as an imaging examination with a radiograph of face profile and a stone cast of the patient’s arches, in order to better visualize the position of retained teeth (Figs. 1B, C). The treatment plan consisted of extracting the elements aforementioned into stages (local), starting from the teeth retained in symphysis region (Figs. 2A, B). After extractions, a plentiful irrigation with 0.9% saline solution was performed, and the osseous bed was prepared to receive subsequent microgranular compound bovine bone graft. A guided bone regeneration was performed with bovine bone biological membrane juxtaposed to the bovine graft (Fig. 2C); the suture of surgical wound was made with simple stitches using 4-0 Vicryl, because of muscle involvement at the moment of surgery. In a second surgical stage, the supernumerary elements from the region of left maxillary and mandibular premolars were removed. And finally, the third molars and teeth erupted in the region of right mandibular premolars were extracted, as requested by the orthodontist, following the same pattern of irrigation, but in this case, the

FIGURE 1. A, Ortopantomography shows the impacted supernumerary tooth. B, Radiograph of the face to better visualize the impacted tooth. C, Stone cast of patient’s arches. D, Clinical aspect at postoperative 1 year. E, Imaging aspect at postoperative 1 year, showing a great healing aspect.

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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

Complete eruption of a deeply impacted tooth in a recurrent keratocystic odontogenic tumor with orthodontic occlusal alignment.

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