Diagnosis and surgical management of impacted mandibular canines associated with a dentigerous cyst and odontoma: A case report

Abstract

In dental practice, impacted canines are common clinical conditions that compromise tooth mobility, thereby severely affecting functionality and esthetics. They also represent a significant challenge, particularly when associated with odontogenic pathologies such as dentigerous cysts and odontomas. These entities, despite benign, can cause complications, including tooth displacement, root resorption, and alterations in normal eruption, compromising both esthetics and function. We present the case of a 15-year-old female patient with no relevant medical history who attended for orthodontic treatment planning. Computed tomography scans revealed bilateral impaction of the mandibular canines, associated with radiolucent images consistent with dentigerous cysts. A mixed radiolucent-radiopaque image was also observed in the area of the lower right first premolar, suggesting an odontoma. Surgical management was proposed, including enucleation of the cysts, removal of the odontoma, and placement of orthodontic appliances on the exposed canines to facilitate their movement. Histopathological analysis confirmed the diagnosis of two dentigerous cysts and one compound odontoma. In the surgical follow-up, the intervention area evolved satisfactorily, with no signs of complications, such as infection, delayed healing, or recurrence of the lesion. One of the most complex clinical challenges is managing impacted mandibular canines when associated with odontogenic pathologies. The implementation of advanced diagnostic tools such as computed tomography, along with appropriate surgical techniques and strategic orthodontic planning, effectively addresses these clinical presentations. Timely multidisciplinary treatment promotes the resolution of associated pathologies and optimizes dental alignment, contributing to improved masticatory function and facial esthetics. These comprehensive approaches are essential to ensure predictable and successful outcomes in certain complex cases.

Introduction

Dental impaction is described as the retention of a dental organ within the bone after the normal eruption time, or when it does not emerge in the oral cavity. This condition occurs when the normal development of the tooth is obstructed or interrupted. The teeth that are most frequently impacted, after the third molars, are the canines. ¹ The prevalence of impacted canines varies among different populations and also among results obtained in various studies, and it generally ranges between 0.8% and 9.5%, with a greater predilection in women than in men. ¹ The maxillary canines are the most commonly affected teeth. ¹ The etiology of this condition is multifactorial, and it may involve genetic, anatomical, and environmental factors. ¹

Canine impaction may be associated with conditions such as dentigerous cysts and odontomas. Dentigerous cyst is an odontogenic pathology that represents ~20%–24% of all jaw cysts. Generally benign and nonaggressive, dentigerous cysts may cause significant displacement or resorption of surrounding structures, including teeth and bone, if left untreated. On the other hand, odontomas are the most common odontogenic tumors in the oral cavity, and they account for 21%–67% of these tumors. If odontomas compromise dental eruption or cause complications such as cystic lesions, surgical removal is essential. ² Due to the unusual nature of the association between these entities, this clinical case was aimed at describing a surgical approach to impacted canines associated with dentigerous cysts and odontomas, as confirmed using histopathological analysis.

Case report

A 15-year-old female patient with no pathological history presented with bilateral impacted mandibular canines associated with dentigerous cysts and an odontoma which were tentatively identified on the radiographs by her treating specialist during orthodontic treatment planning (Figure 1(a)). Computed tomography (CT) showed a well-defined unilocular and radiolucent lesion on 33 and 43 (Figure 1(b)). Additionally, a mixed radiolucent and radiopaque image with defined radiopaque edges was identified at the level of the middle third of the right first premolar, in association with an odontoma (Figure 1(c) and (d)). Intra-oral clinical evaluation revealed the absence of permanent teeth 33 and 43 and the presence of temporary canines 73 and 83 (Figure 2(a)).

Figure 1.

Results from radiographic studies. (a) Orthopantomography showing two well-defined radiolucent lesions ~15 and 11 mm in diameter, respectively, with well-defined radiopaque margins around the crowns of teeth 33 and 43, characteristic of cysts. (b) Cone-beam CT demonstrating well-defined unilocular radiolucent lesions associated with teeth 33 and 43. (c) A mixed radiolucent and radiopaque image with defined radiopaque borders at the middle third of the right first premolar, indicating an odontoma. (d) CT scan showing cystic cavities surrounding each of the canines.

Figure 2.

Surgical procedures used. (a) Intraoral clinical evaluation revealed the absence of permanent teeth 33 and 43 and the presence of deciduous canines 73 and 83. (b) An intrasulcular incision from 36 to 45 made to elevate a full-thickness mucoperiosteal flap. (c) Extraction of the deciduous canines, and a circular osteotomy performed using a surgical handpiece to create a bony window and expose the entities. (d) Osteotomy performed to expand the area corresponding to tooth 43 for improved visibility. (e) The identified odontoma. (f) A button cemented to the exposed coronal portion of the canines, and wires connected from the button to the orthodontic appliance.

A surgical intervention was performed under local anesthesia with articaine and epinephrine at a volume ratio of 1:100,000. To access the lesion, a 36–45-inch intrasulcular incision was made to achieve elevation of a full-thickness mucoperiosteal flap (Figure 2(b)). Then, soft tissue debridement was performed, and the deciduous canines were extracted. A thinned and more transparent oral cortical wall was seen corresponding to the entities identified in the imaging. A circular osteotomy was performed with a surgical handpiece under copious irrigation with sterile saline, in order to create a bony window and expose the entities. For the enucleation of the tentative cysts, Lucas curette and mosquito forceps were used to remove the capsule and tissue (Figure 2(c)). Subsequently, the area corresponding to dental organ 43 was expanded with osteotomy for better visibility (Figure 2(d)), in order to enhance the removal of the odontoma (Figure 2(e)). The surgical defect was debrided to remove soft tissue debris and expose healthy bleeding bone tissue. The capsules, surrounding tissues, and tentative odontoma were fixed in formaldehyde solution prior to histopathological analysis. A canine traction was established by cementing a button on the exposed coronal portion of each canine, along with wires from the newly placed button to the orthodontic appliance (Figure 2(f)). The surgical site was vigorously irrigated with sterile saline, and the flap was repositioned and sutured with simple 5–0 vicryl sutures. Histopathological findings confirmed the presence of a compound-type odontoma (Figure 3(a)) and two dentigerous cysts corresponding to the right (Figure 3(b)) and left mandibular canines (Figure 3(c)), thereby corroborating the clinical and radiographic diagnosis.

Figure 3.

Histopathological sections confirming the presence of an odontoma and two dentigerous cysts. (a) Compound odontoma characterized by a hamartomatous proliferation of dental tissues. Histologically, the lesion exhibits enamel matrix (black arrow), tubular dentin (white arrow), pulp-like connective tissue, and islands of odontogenic epithelium arranged in a manner resembling rudimentary tooth structures (arrowhead). These elements are embedded within a moderately dense fibrous stroma. (b) Dentigerous cyst (left side): histological section shows a cystic cavity lined by nonkeratinized stratified squamous epithelium, five to eight cell layers thick (black arrow), supported by adjacent fibrous connective tissue. (c) Dentigerous cyst (right side): cystic structure lined by nonkeratinized squamous epithelium, one to two cell layers thick (black arrow). The underlying connective tissue stroma is fibrous, with focal myxoid changes (white arrow).

Postoperative care focused on the prevention of infections, pain control, and proper healing. Amoxicillin and clavulanic acid were administered as antibiotic therapy every 12 h for 7 days. Moreover, chlorhexidine gel was applied to the surgical site twice a day for 14 days to promote local disinfection and avoid bacterial colonization. In addition, the patient was advised on general measures such as avoiding strong rinses, consuming soft foods, and maintaining adequate oral hygiene in nonintervened areas.

After the surgical intervention, active chains were placed on the cemented metal buttons in each canine, attached to a flexible steel wire of 0.016 inches. A light and continuous mechanical force was applied to promote gradual and controlled traction, with the chain reactivated on a monthly basis. This progressive activation favored the movement of the canines without causing periodontal alterations or loss of anchorage, being clinically supervised at each review.

In addition to the surgical management, a comprehensive periodic follow-up plan was implemented. The patient attended her monthly check-ups over 6 months following surgery. In the surgical follow-up, the intervention area evolved satisfactorily, with no signs of complications, such as infection, delayed healing, or recurrence of the lesion. Regarding the orthodontic follow-up, stability of the attachments and a favorable response to traction in the canines were observed, with progressive movements in the mesio-occlusal direction toward an adequate functional position in the arch. This resolution supports the initial assurance and effectiveness of the multidisciplinary approach undertaken (Supplemental Material).

Discussion

Currently, impacted canines are considered one of the biggest challenges faced by dentists in clinical practice.^1,2 There are a few clinical case studies in the literature that describe multidisciplinary surgical management of impacted mandibular canines for orthodontic traction associated with dentigerous cysts and odontomas. The diagnosis of impacted canines requires detailed clinical evaluation and imaging examination so as to achieve enhanced precision. In addition, there is need for adequate and careful treatment planning.

CT is a primary tool that functions as a guide to making correct diagnosis, and it allows for structuring of the treatment plan and prognosis for impacted canines.^{1,3 –6} In the present case, the identification of the impacted canines associated with these entities was attributed to panoramic radiographs and CT scans requested for planning of orthodontic treatment. These instruments allow for early detection of dentigerous cysts which cause complications such as facial asymmetry, bone expansion, significant displacement of teeth, or root resorption of adjacent teeth.^3,4,6 Moreover, dentigerous cysts may undergo neoplastic changes and develop into pathologies such as ameloblastoma, squamous cell carcinoma, or mucoepidermoid carcinoma. Likewise, panoramic radiographs and CT scans enhance the identification of odontomas which cause prolonged retention of primary teeth, delayed eruption of permanent teeth, and root resorption of adjacent teeth. ² This underscores the importance of using appropriate diagnostic tools for the diagnosis of impacted teeth and the associated entities.

Therapeutic modalities for impacted canines depend on various factors such as the position of the tooth, the age of the patient, and associated pathologies. The treatment options comprise periodic surveillance, extraction, and surgical-orthodontic management. ⁷ In surgical-orthodontic management, the techniques used for exposure of impacted canines are classified into two categories: open and closed interventions. In the case of buccal impaction, Kokich ⁸ proposed three surgical methods: gingivectomy, apical flap, and the closed technique. Selection of the appropriate technique depends on the buccolingual location of the canine, its vertical position relative to the muco-gingival junction, the mesiodistal position, and the amount of keratinized gingiva present. If the impacted canine is coronally positioned, with adequate gingival thickness (2–3 mm of attached gingiva), any technique may be used. Conversely, if the impacted canine is apically positioned relative to the mucogingival junction and mesiobuccal to the lateral incisor root, an apically positioned flap is suggested. Similarly, when the canine is impacted apically to the mucogingival line, the closed technique is applied.

In the present clinical case, in view of the dimensions of the cysts, the depth of the retained tooth, the limited arch space, and the required trajectory for the final positioning of the tooth’s final positioning, a decision was made to use the closed technique which involved enucleation of the cysts, extraction of the odontoma, and installation of orthodontic appliances during the same surgical procedure. This decision was informed by two reasons: (a) to ensure adequate access to and visibility of the impacted dental organs for ease of removal of cyst and odontoma and (b) to facilitate the implementation of orthodontic attachments on teeth 33 and 43, thereby aiding their future traction and correct positioning in the dental arch for each canine. In this technique, it is crucial to closely monitor tooth movements, in view of potential dislodgement of orthodontic attachments during the traction process. This management approach is consistent with the strategy proposed by Beltrán et al. ⁷

On the other hand, some authors have suggested that the optimal therapeutic option for patients with dentigerous cyst associated with impacted tooth is orthodontic traction following marsupialization, provided that adequate space is available for the dental organ.^{3,4,5,9 –11} Marsupialization is a surgical procedure that reduces intra-cystic pressure and decreases cyst size through an opening that drains cyst contents, thereby facilitating the eruption of the tooth associated with the cyst. However, this surgical approach has some disadvantages such as prolonged postoperative recovery and discomfort associated with an open wound.

The present clinical case illustrates how adopting a coordinated surgical-orthodontic approach from the diagnostic stage strengthens clinical timing and functional resolution in patients with dental impaction linked to odontogenic pathologies. A simultaneous intervention allows not only the removal of pathological lesions but also facilitates an immediate transition to orthodontic treatment, representing an advantage in terms of clinical efficiency and reduction in the total number of interventions. This strategy manages to align surgical and orthodontic objectives in a therapeutic act, contributing to more objective, predictable, and patient-centered planning.

Likewise, it is essential to have a multidisciplinary team available for complex cases, in which the participation of a surgeon, pathologist, and orthodontist is important to guarantee safe, stable, and esthetically satisfying outcomes. Although long-term data are not available, the initial postoperative evolution has been clinically adequate. In the 6 months following the surgical approach, the patient has been reviewed regularly, and complications such as delayed healing, dehiscence, infection, or recurrence of cystic lesions have not been identified. Additionally, orthodontic treatment has progressed favorably in the traction of the impacted canines; thus, these reviews have allowed for the proper evolution of the treatment to be supervised. Periodic clinical and radiographic follow-up is essential in order to monitor the long-term stability of the intervention and to identify possible recurrences or late complications. Within this context, this periodic monitoring will help to estimate the effectiveness of orthodontic traction and, as well, the esthetic and functional position of the canines.

Conclusion

The management of affected mandibular canines, often accompanied by dentigerous cysts and odontomas, poses a significant challenge in dental clinical practice. In the present clinical case, the integration of an advanced diagnostic imaging instrument, such as CT, with direct management through the enucleation of lesions and the placement of orthodontic attachments in the same surgical intervention allowed for effective and optimal access to the structures involved, reducing the total time of treatment by favoring the early traction of the impacted canines. This comprehensive multidisciplinary approach proves to be valuable and an effective alternative in the presence of odontogenic pathologies linked to dental inclusion.

Supplemental Material

sj-pdf-1-sco-10.1177_2050313X251371958 – Supplemental material for Diagnosis and surgical management of impacted mandibular canines associated with a dentigerous cyst and odontoma: A case report

Supplemental material, sj-pdf-1-sco-10.1177_2050313X251371958 for Diagnosis and surgical management of impacted mandibular canines associated with a dentigerous cyst and odontoma: A case report by Fernando Gutiérrez-Maldonado, Gustavo Eder González-Alvarez, Melissa Martínez-Nieto, Mario Alberto Alarcón-Sánchez, Lilibeth-Stephania Escoto-Vasquez, Artak Heboyan, Ruth Rodríguez-Montaño and Sarah Monserrat Lomelí-Martínez in SAGE Open Medical Case Reports