Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2006  |  Volume : 24  |  Issue : 2  |  Page : 97--99

Unusual presentation of inverted impacted premolars as a result of Dentigerous cyst: A case report


ND Shashikiran, NC Kumar, VVS Reddy 
 Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Davangere, Karnataka, India

Correspondence Address:
N D Shashikiran
Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Davangere - 577 004, Karnataka
India

Abstract

A case of dentigerous cyst associated with upper right lateral incisor that had resulted in displacement of the canine, inverted impaction of both the premolars and dilaceration of apical 1/3 of central incisor is reported here.



How to cite this article:
Shashikiran N D, Kumar N C, Reddy V. Unusual presentation of inverted impacted premolars as a result of Dentigerous cyst: A case report.J Indian Soc Pedod Prev Dent 2006;24:97-99


How to cite this URL:
Shashikiran N D, Kumar N C, Reddy V. Unusual presentation of inverted impacted premolars as a result of Dentigerous cyst: A case report. J Indian Soc Pedod Prev Dent [serial online] 2006 [cited 2020 Jan 21 ];24:97-99
Available from: http://www.jisppd.com/text.asp?2006/24/2/97/26024


Full Text

 Introduction



Tooth impaction is a frequently observed anomaly of eruption in pediatric dental practice. The teeth most commonly impacted are the mandibular third permanent molar, maxillary permanent canine and occasionally the premolars.[1] This impaction can be horizontal, vertical, mesioangular, distoangular or inverted of which inversion is very rare.

Inversion is defined as "the malposition of a tooth in which the tooth has reversed and is positioned upside down".[2] Inversion of the premolar is very rare with few cases reported in the literature and majority of these are limited to radiological findings.[3]

One of the complications of impacted teeth is the formation of cyst especially the dentigerous cyst. Dentigerous cyst is a cyst that originates by the expansion of the follicle around the crown of an unerupted tooth.[4] The dentigerous cysts accounts for 20% of all the epithelial cysts of the jaws.[5]

Young patients with impacted or unerupted teeth have more predilection for dentigerous cyst formation. So, their early recognition and treatment is a must to prevent its further growth if not, would lead to osseous deformities and destruction.[6] Here is a case report where-in there is a dentigerous cyst associated with lateral incisor causing the inversion of premolars.

 Case Report



A 12 year old boy reported to the Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, with a complaint of pain in the upper front teeth since two months. On clinical examination, a partially erupted upper right central incisor was seen. Right lateral incisor and canine were missing associated with a palatal swelling. The upper right second deciduous molar showed deep dentinal caries. In the lower arch the left second deciduous molar was grossly destructed.

Radiographs revealed a large dentigerous cyst associated with upper right lateral incisor and the displacement of upper right canine almost near to the orbital floor. In addition, dilaceration of apical 1/3 of right central incisor and inverted impaction of both the upper right premolars were noticed [Figure 1][Figure 2].

Based on the clinical examination and the radiological findings, the treatment options considered were

(i) Surgical enucleation of the dentigerous cyst associated with impacted upper right lateral incisor, followed by orthodontic traction for the correction of inverted impacted premolars and alignment of the canine into the oral cavity later followed by complete orthodontic treatment.

(ii) Surgical enucleation of the dentigerous cyst associated with impacted upper right lateral incisor and both the premolars followed by replantation of the premolars in the proper direction.

(iii) Surgical enucleation of dentigerous cyst associated with impacted upper right lateral incisor, followed by extraction of all the impacted teeth under general anesthesia.

So prior to the surgery, routine examinations like blood analysis (TC, DC) and urine analysis were carried out.

Under general anesthesia, the labial and the buccal flaps were reflected, enucleation of the cyst along with the extraction of lateral incisor was carried out and sent for histopathological examination. The enucleation revealed the presence of a large cavity in the upper right quadrant. Through this large cavity we were able to see the displaced canine which was very much highly placed almost near to the orbital floor and the inverted premolars. As the cavity was too large, the first 2 options of treatment were ruled out and the last option i.e., extraction of all the impacted teeth along with the deciduous tooth was carried out. After extraction, the flaps were placed in its original position and sutured. The patient was discharged on the next day without any complications. The patient was recalled after 8 days and sutures were removed and the wound healed uneventfully [Figure 3].

Histopathological examination

Microscopic examination of the sections revealed a cystic lumen with very thin epithelium comprising of only 1-3 layers. The connective tissue capsule had capillaries, some of them dilated and engorged with RBC's. Areas of inflammatory cell infiltrate were seen [Figure 4]. All these features suggested of infected dentigerous cyst.

 Discussion



This is a rare case of inverted impaction of premolars. Some of the etiological factors that may result in an inverted impaction are

(i) Systemic conditions like

- Nutritional disorders

- Endocrine disorders

(ii) Previous trauma/stimulation to the affected site during tooth growth

(iii) Abnormal location of tooth bud during initiation

(iv) Follicular tooth sac inflammation.

As the patient was well built, well nourished and had no history of any trauma to the affected side during tooth growth. Systemic conditions or trauma that resulted in inversion of premolars was not considered.

The position of the tooth bud might have been abnormal in the initial developmental stage of the tooth. It may be possible that the tooth had been impacted transversely and was further inverted by some external force.[8] So, in this case, the tooth inversion was most probably because of follicular tooth sac inflammation from the dentigerous cyst, associated with the upper right lateral incisor which might have exerted some force on the premolars and also resulted in the displacement of upper right canine and dilaceration of apical 1/3 of the upper right central incisor.

This case also suggests that although there were many treatment options based on clinical and radiological findings, the third option was considered as surgical exploration revealed a large cavity and hence the first two options were questionable.

References

1Ishikawa G, Akiyoshi M. Oral pathology I. Nagasue: Kyoto; 1971. p. 50-5.
2Mody RN. A completely inverted impacted mandibular second premolar. J Ind Dent Assoc 1972;55:273-4.
3Tsubota F, Ritamure HA. Consideration on the mechanism of transposition of the teeth. Kanawa Sigaku 1978;12:193-211 (In Japanese).
4Lushman J, Shear M. J Oral Surg 1985;17:153-61.
5Bhaskar AW. J Br Dent Assoc 1981;12:61-5.
6Bhasker SN. Nonsurgical resolution of radicular cysts. Oral Surg Oral Med Oral Pathol 1972;34:458-68.
7Nowure Y, Sekiya T. One case of topsy-turvy impaction of tooth with interesting process. Shikaiqaku 1956;19:67-8 (In Japanese).
8Farmer ED, Lawton FE. Stone's Oral Dental Diseases. E.I.B.S. ed, E and S Livingstone Ltd: 1966.