Year : 2010 | Volume
: 28 | Issue : 2 | Page : 116--120
Paradental cyst of the first molar: A report of two cases
AE Borgonovo, S Speroni, A Fabbri, GB Grossi
Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, UniversitÓ degli Studi di Milano, Milan, Italy
Via primavera n░1, 28925 Verbania (VB)
Objective: The paradental cyst is an uncommon lesion associated with the permanent mandibular first or second molar in children just prior to tooth eruption. The purpose of this article is to present two cases of paradental cyst affecting the buccal aspect of permanent mandibular first molar of both young patients. We also discuss diagnosis, treatment and radiographic findings of the cases. Patients and Methods: In both cases was made only the enucleation of cyst without extraction of the adjacent tooth. Lesional samples were sent for histopathologic analisis. Results: The histopathologic analisys of both cases, revealed a lining of hyperplastic, nonkeratinized squamous epithelium with heavy, dense inflammatory cell infiltrate in the epithelium and connective tissue wall. The histopathology associated with macroscopic and radiographic examination permitted the definitive diagnosis of a paradental cyst on the mandibular left first molar. A follow-up of 1 year was carried out in both cases and no recurrences was noted; in the first case was observed the correct eruption of the mandibular permanent left first molar. Conclusions: A clinicopathologic correlation, incorporating the surgical, radiographic, and histological finding, is required to obtain the final diagnosis of paradental cyst. Today, the treatment of choice is simple enucleation and thorough curettage of the cyst without extraction of the involved tooth.
|How to cite this article:|
Borgonovo A E, Speroni S, Fabbri A, Grossi G B. Paradental cyst of the first molar: A report of two cases.J Indian Soc Pedod Prev Dent 2010;28:116-120
|How to cite this URL:|
Borgonovo A E, Speroni S, Fabbri A, Grossi G B. Paradental cyst of the first molar: A report of two cases. J Indian Soc Pedod Prev Dent [serial online] 2010 [cited 2020 Aug 15 ];28:116-120
Available from: http://www.jisppd.com/text.asp?2010/28/2/116/66753
A paradental cyst is also called as "paradental inflammatory cyst," since the inflammation has an important role in its pathogenesis. The term "paradental" means that such type of cysts have relationships of proximity with the root of a tooth.
The etiology of these cysts is still debated, but it is believed that they originate from the reduced epithelium of enamel , or from the inflammatory proliferation of epithelial rests of Malassez , that come from the superficial mucosa of a tooth in eruption (pericoronitis).  They represent beyond 5% of all odontogenic cysts. ,
Some cases of paradental cyst are asymptomatic and are diagnosed incidentally from a radiograph,  whereas others remain undetected by clinical examination and radiograph. 
The major clinical features of the paradental cyst are the presence of a recurring inflammatory periodontal process, usually a pericoronitis. Apart from acute episodes, this cyst presents only a few signs and mild symptoms, including moderate pain, discomfort, tenderness, and in some cases, suppuration through the periodontal sulcus. ,,
The purpose of this article is to present two young cases with paradental cysts affecting the buccal aspect of permanent mandibular first molar. We also discuss diagnosis, treatment and radiographic findings of the cases.
A 7-year-old boy was referred to Oral Surgery department, Dental Clinic, IRCCS Foundation Hospital, Milan, Italy, for the evaluation of a swelling located on the buccal aspect of the unerupted mandibular left first molar. Clinical signs of inflammation were absent and the mucosa around the involved site appeared clinically normal.
The evaluation of panoramic radiograph revealed radiolucency, demarcated by a fine radiopaque line situated around the roots of the mandibular left first molar [Figure 1].
Computed tomography showed that the margins of radiolucent lesion were delimited by a thin layer of denser bone on the buccal aspect [Figure 2]. The clinical, radiographic and anamnestic features suggested the initial diagnosis of paradental cyst.
We decided for a surgical removal of the lesion under general anesthesia. The surgical approach involved a trapezoidal flap with vestibular ostectomy, and the cyst was treated by enucleation. The extraction of the left first mandibular molar was not necessary [Figure 3]. Irrigation with sterile saline was done and a suture was made with silk 4/0 .
Microscopically, the cyst was lined by a hyperplastic, nonkeratinized squamous epithelium. A heavy inflammatory infiltrate of mononuclear and polymorphonuclear cells was observed in the epithelium and connective tissue wall. The fibrous wall showed multinucleated giant cells associated with the thickness of the blood vessel wall.
The histopathology associated with macroscopic and radiographic examinations permitted the definitive diagnosis of a paradental cyst on the mandibular left first molar. A follow-up of 1 year was carried out. The panoramic radiograph and clinical examination, performed after 6 months, evidenced complete regression of the lesion and the correct eruption of the mandibular permanent left first molar [Figure 4]. Healing of bone was complete radiographically 12 months after surgery.
A 8-year-old boy presented with the complaint of swelling over the buccal gingiva of his lower left partially erupted first molar. He complained of pain on chewing. All the other teeth were asymptomatic. Clinically, there was mild edema in the overlaying mucosa of the partially erupted tooth. The lower left first molar was caries free but mildly tender on percussion; electric pulp testing was positive. The panoramic radiograph showed well-defined ovoid radiolucency on the buccal aspect and extending apically on the mandibular left first molar. The radiolucency was about 10 Χ 15 mm and involved the mesial and distal roots; it was surrounded by a sclerotic margin [Figure 5]. Computed tomography showed the presence of the cyst and its relation to the molar; there was an expansion of cortical bone with a peripheral sclerotic border. The cyst started from the cemento-enamel junction and extended beyond the apex of the involved tooth [Figure 6].
The treatment plan was to enucleate the left cyst and maintain the affected tooth. We made a gingival crevicular incision with vertical releasing incisions to create a trapezoid-shaped flap. After mobilization of the full-thickness vestibular mucoperiostal flap, vestibular ostectomy was done, the cyst was exposed, and it was enucleated through this access [Figure 7]. Irrigation with sterile saline was carried out and a suture was made with silk 4/0.
Microscopically, the lesion consisted of a lining of nonkeratinized, stratified squamous epithelium with areas of hyperplasia. It showed a dense chronic inflammatory infiltrate in the connective tissue wall of the cyst, supporting a definitive diagnosis of a paradental cyst.
After 6 months of surgery, a complete eruption of the tooth was observed and the panoramic radiograph performed 1 year after the enucleation showed a complete bone regeneration; no recurrence was noted [Figure 8].
The paradental cyst was included in the World Health Organization (WHO) histologic typing of odontogenic tumors for the first time in 1992, although it had been described in several clinicopathologic studies in specialized journals since 1970. ,,[4,] Most cases described in literature till date have occurred in mandibular third molars, and less frequently in second , and first molars, ,,,, and rarely in premolars  or incisors/canines. 
The paradental cyst is localized exclusively in the mandibular region, nearly always on the distal or vestibular surface of a completely or partially erupted molar, but always vital. Although the mesial surface could be involved very rarely, , the lingual aspect is never interested . Beyond 60% of the cases of paradental cysts are associated with the lower third molars. 
Since the radiologic features are different according to the tooth involved,  we can distinguish the paradental cysts developed on the first and second inferior molars, also called as "juvenile paradental cysts,"  from those involving the inferior third molar.
The medium age of the patients with paradental cyst localized at the lower first molar is 8-9 years, whereas cysts localized to the molar appear between 13 and 20 years of age. Bilateral localizations are marked in 23.6% of the cases. 
The clinical symptoms and signs are those of the periodontitis and are common to both localizations, while the insorgence of a vestibular swelling seems to be associated exclusively to the paradental cysts that involved the first molar. 
Since the lesion is localized on vestibular aspect of the roots, the involved molar is usually tilted so that the root apices are adjacent to the lingual cortex with the crown showing buccal tipping. 
According to Stoneman et al., the nearly exclusive involvement of the vestibular surface would be explained by the fact that the mesio-buccal cuspids are the first to perforate the oral mucosa during the eruption, and therefore, the first to be exposed to the oral ambient.
It has been stated that the radiographic image of the paradental cyst involved the first or second molar, and is always characterized by a well-defined radiolucency associated with the roots on the buccal aspect. [1,4]
The medium age of the patients with paradental cysts localized at the lower third molar is approximately 25-30 years, and bilateral localizations are marked just in 4.1% of the cases.  In these cases of paradental cyst, localization is distal or disto-vestibular to the third molar.
A history of recurrent pericoronitis is reported usually and there is often the presence of a communication between the periodontal pocket and the cyst. The cortical expansion of the bone is not so frequent like in the forms previously described, and the majority of lesions do not exceed 15 mm of diameter. 
In this article, we have presented two cases of paradental cysts involving the first permanent mandibular molar. In both the cases, the radiographic image of the paradental cyst was characterized by a well-defined radiolucency associated with the roots on the buccal aspect. The differential diagnosis included the radicular cyst, odontogenic keratocyst, lateral periodontal cyst, gingival cyst, dental follicles and the dentigerous cyst. Most studies ,,,, report that a positive electric pulp test is a diagnostic criterion for paradental cyst. The diagnosis would be a lateral radicular cyst if the associated tooth is nonvital.  In the first case the tooth involved was unerupted, but in the second case the electric pulp testing was positive. The initial diagnosis of paradental cyst was made considering the anamnestic, clinical and radiologic features in both the cases. Only the enucleation of cyst without extraction of the adjacent tooth was done in both the cases. Most reports ,,,, show that if the tooth involved is the first or the second molar, the treatment of choice is enucleation of the cyst without the extraction of the tooth. Pompura et al. presented 44 cases treated by enucleation without extraction. Packota et al. successfully treated five cases of paradental cyst involving the mandibular first molar with enucleation of the cyst without extraction. In Wolf and Hietanen's report,  of all the cases of mandibular infected buccal cyst (paradental) associated with the first molar (three cases) and the second molar (three cases), four were treated without extraction. In Vedtofte and Praetorius's  series involving the mandibular first and second molars, 11 of the 13 cases treated with preservation of the involved tooth had successful outcome.
Histologic features of paradental cyst are similar to those of other inflammatory odontogenic cysts. ,,,, The walls of fibrous connective tissue show dense, chronic inflammatory cell infiltration and are lined by a nonkeratinized stratified squamous epithelium of varying thickness and morphology, according to the extent of inflammation. In both the cases previously described, the lesions consisted of a lining of hyperplastic, nonkeratinized squamous epithelium with heavy, dense inflammatory cell infiltrate in the epithelium and connective tissue wall, supporting a definitive diagnosis of a paradental cyst.
A clinicopathologic correlation, incorporating the surgical, radiographic and histologic findings, is required to obtain the final diagnosis of paradental cyst.
Today, the treatment of choice of the paradental cyst involving the mandibular permanent first or second molar is simple enucleation and thorough curettage of the cyst without extraction of the involved tooth.
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