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Accurate localization of impacted supernumerary tooth associated with dentigerous cyst Spiral CT evaluation

– -AAcase case report report

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defined as

Supernumerary teeth may be defined as any teeth or tooth substance in excess of the usual configuration of twenty deciduous, and thirty-two permanent teeth. Schulze C.1970 Page 4

• Dichotomy of the tooth bud • Local, independent, conditioned hyperactivity of the dental lamina • Hereditary

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Prevalence • Single supernumeraries - 76 to 86% • Double supernumeraries -12 to 23% • Multiple supernumeraries - < 1% So LLY. 1990 Page 6

Effects of supernumerary teeth on the developing dentition Crowding Failure of eruption Diastema Root resorption Dilaceration Loss of vitality.

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Case report

25yr old female pt Pain in upper front teeth region since 6 months and pain on pressing in the nostril since 9 months O/E- Dental caries irt 11, 12, no swelling, sinus opening Tender on percussion irt 11, 12 EPT-delayed response irt 11, 12 Page 11

PREOPERATIVE RADIOGRAPH •Coronal radioluscency approaching pulp irt 11,12 •A periapical radioopacity resembling tooth •A large periapical radioluscency irt 12,11,21 Page 12

Post endo

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Spiral CT- Trans axial images

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Trans axial images

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Sagittal view

Inverted supernumerary tooth, not fused Page 17

Coronal view Pericoronal radioluscency

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Oblique releasing incision

Intrasulcular incision

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Elevation of the flap

Exposure of the lesion

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Exposure of the huge lesion

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Enucleation of the lesion

Exposure of the supernumerary tooth

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Removal of supernumerary tooth with bayonet forceps

Supernumarary tooth removed

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Extracted tooth & the lesion

Corrugation of the epithelial remnants

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Immediate post op

Specimen for histopathological examination

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Post endo

Immediate post op after surgery

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H & E stained soft tissue section 2-3 layered Nonkeratinized SS epithelium Collagen fibers

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Connective tissue

Chronic inflammatory cells

Diagnosis â&#x20AC;&#x201C; Dentigerous cyst Page 31

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• Impacted teeth are often encountered in routine radiographic examination • In treatment planning, it is imperative to accurately locate them and determine their relationships to adjacent teeth and anatomical structures in the area. • Usually, the required information can be obtained from periapical, occlusal, or panoramic radiographs. • Radiographs are important in assessing the location and nature of these anomalies.

• The major shortcoming of the conventional radiography for the assessment of impacted teeth is the overlapping of structures on the film. • This problem makes it difficult to distinguish a particular detail, especially when structures differ only slightly in density. • CT has proved to be superior to other radiographic methods in visualizing bone tissue. It overcomes the limitations of conventional radiographs • Compared with conventional plain films, 3D CT images clearly show the intraosseous location, inclination, and morphology of impacted teeth, as well as distances from adjacent structures.

Multiplanar reformation images of the tooth revealed

Trans axial images • showed impacted tooth located palatal to 11,21 measuring 1.4x1.5cm Coronal image • showed inverted supernumerary tooth, which was not fused with 11, pericoronal radioluscency around the impacted tooth which was seen as periapical radioluscency involving 12,11 and 21 in the conventional radiographs Sagittal images • showed inverted supernumerary tooth measuring 1.02cm and which was not fused with the surrounding tooth.

• Dentigerous cyst (24% of jaw cysts) is one of the most common developmental odontogenic cysts which is usually detected on routine radiographic examination. • A dentigerous cyst can be defined as one that encloses the crown of an unerupted tooth by expansion of its follicle and is attached to its neck. • Mandibular third molar and maxillary canine are commonly involved followed by mandibular premolar and maxillary third molar and very rarely central incisor, deciduous teeth and supernumerary teeth • Although dentigerous cyst is a common developmental cyst, its association with supernumerary teeth is RARE and estimated to constitute 5-6% of all dentigerous cysts

• The radiolucency usually arises in the cemento-enamel junction of the tooth. • If a follicular space on the radiograph is more than 5 mm, an odontogenic cyst can be suspected.

• Differential diagnoses of such radiolucency include  Odontogenic keratocyst  Radicular cyst  Odontogenic tumors  Ameloblastoma  Pindborg’s tumor  Odontoma  Odontogenic fibroma  Cementoma

JODDD, Vol. 5,

No. 2 Spring 2011

Guidelines for the diagnosis of a dentigerous cyst Daley and Winsock

1) A pericoronal radioluscency >4 mm in greatest width, 2) Histologically, fibrous tissue lined by nonkeratinized stratified squamous epithelium 3) A surgically demonstrable cystic space between the enamel and the overlying tissue.

â&#x20AC;˘ Mesiodens is known to have a cone shaped crown and a short root as seen in our patient. â&#x20AC;˘ Some untreated dentigerous cysts rarely have potential to develop odontogenic tumors like ameloblastoma and malignancy like oral squamous cell carcinoma, mucoepidermoid carcinoma and also cholesterol clefts which are more common in radicular cysts because of constant inflammatory condition.

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conclusion â&#x20AC;˘ When an unerupted supernumerary tooth is evident the direction of the crown, the location, the influence on adjacent teeth, resorption of adjacent roots and the formation of dentigerous cysts should be carefully evaluated .Early detection comprising of a thorough clinical, radiographical examination and advanced diagnostic aids is necessary for accurate diagnosis to prevent associated complications.

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References • • • • • • • •

INTERNATIONAL JOURNAL OF DENTAL CLINICS 2010:2(2): 39-42 Journal of Dental Research, Dental Clinics, Dental Prospects INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(1):77-78 Journal of Clinical and Diagnostic Research , 2010 June ; 4:2601-2606. Journal of Clinical and Diagnostic Research , 2010 June , 4:2601-2606. Journal of Clinical and Diagnostic Research, 2010 June , 4:2601-2606. Journal of Clinical Rehabilitative Tissue Engineering Research January 22, 2011 Vol.15, No.4 Oral surgery, Oral medicine, Oral pathology, Oral surgery and Endodontology- vol 105,1, Jan 2008

• • •

Australian Dental Journal 1997;42:(3):160-5 American Journal of Orthodontics and Dentofacial Orthopedics Volume 130, Number 1 Journal of Clinical Rehabilitative Tissue Engineering Research January 22, 2011 Vol.15, No.4


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