Mandibular Buccal Infected Cyst (buccal infected cyst)
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While the main cause of
a dental abscess in a child is a periapical lesion due to a badly carious
or fractured and non-vital tooth, abscesses can occasionally
be attributed to reasons other than these. Such is the case with a mandibular
buccal infected cyst, also known as paradental cyst, and buccal bifurcation
cyst. Manibular buccal infected cyst is an inflammatory lesion involving the
buccal and distalobuccal aspects of the mandibular permanent molars, and is
usually attached to the cervical margins extending down to the root bifurcation
(1). It rarely affects other teeth; it has been shown to involve the permanent
premolar teeth (2). Although infected, often with suppuration, the associated
teeth are vital. Some investigators believe that the paradental cyst is the
same entity as buccal infected cyst that mainly affects a partially erupted
mandibular third molar tooth. Several factors have been implicated in the origin
of this cyst, including its origin from the epithelial rests of Malassez, the
dental follicle around the erupting tooth, the crevicular epithelium, and the
reduced enamel epithelium. Occasionally the involved tooth has a small enamel
spur of pearl in the furcation area that may cause the inflammatory process
(1-3). These cysts are frequently misdiagnosed as inflammatory dentigerous
cysts, lateral radicular or lateral periodontal cysts (2-4). They affect children
around 8-13 years of age, and are more common in males (1-4). Paradental variant
tends to occur in older patients around 24 years of age. Patients usually present
with buccal gingival swelling, pain, and at times a sinus tract releasing pus.
These cysts are often bilateral, which was the case in this patient. Clinically
the patient had the defect involving teeth #s 18 and 31. Radiographically,
however, only tooth #31 showed the typical features.
Radiographically, these cysts are readily diagnostic with specific features, including the presence of a periodontal defect buccal and distal to the involved tooth, buccal expansion of the buccal cortical bone. Teeth are displaced lingually and usually the adjacent non-erupted tooth shows no evidence of an increased follicular space. However, on occasions radiographic changes are not as readily detectable as is the case with tooth #18 in this case (Fig 3) where clinically the tooth had a defect probing 5-6 mm while radiographically no changes were detected. The histology is non-specific. It may be very similar to a radicular cyst, periodontitis or an inflamed dentigerous cyst. There is usually loose and vascular granulation tissue wall, lined by stratified squamous epithelium with intense inflammatory cells, and often with abscess formation. All of these features were present in the histologic specimen from our case. The treatment of choice is enucleation and preserving the involved tooth (1-4). The teeth usually grow normally. Recurrence is rare and may be attributed to incomplete removal of the lesion.
Flap surgery on tooth # 31 with curettage biopsy and the surgical extraction of tooth # 32 was performed on 05/28/2004. Following the extraction of tooth # 32 and curettage of the soft tissue (Fig 3), the osseous crater defect extending from the distal root surface of tooth # 31 and incorporating the third molar crown site was substantial. A mixture of mineralized freeze-dried bone allograft with tetracycline powder was placed to fill the space, providing a clotting medium and supporting the flaps by creating a full closure over the surgical site. A primary closure was achieved with the placement of four interrupted loop sutures. The tissue samples were submitted to the Oral Pathology Biopsy Service for a microscopic evaluation and a definitive diagnosis. The healing response was evaluated at one, two (sutures removed), four, eight and sixteen weeks. The early healing progressed without suppuration and new bone has progressively regenerated the base of the pocket. A Monoject 412 syringe has been used to irrigate the decreasing pocket and for debridement of trapped particles.
Figure 3. Area of tooth # 31 after treatment (view w/ graft).
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