Case seen by Dolphine Oda, BDS, MSc; submitted by Wesley Hanson DDS MSD

Figure 1.  A curved line along the buccal aspect of tooth #31 corresponding to the 10 + mm pocket clinically detected along the distobuccal aspect of this tooth.

A 12-year-old healthy Caucasian male presents to his General Dentist office for a routine dental examination, radiographs and dental prophylaxis in 2004.

History of Present Illness

The subsequently identified lesion was not symptomatic and without objective evidence of disease. The Panoramic x-ray revealed a deep, radiolucent area of bone loss at the distal of tooth # 31 (Fig 1) that extended distally to the follicular sack surrounding the developing crown of tooth # 32. The asymptomatic, periodontal pocket measured 10 mm along the disto-buccal of tooth # 31.

Medical History

Other than a routine appendectomy surgery on February 2004, the patient’s medical history was unremarkable. Both Vicodin and Morphine had been prescribed post-surgically but no medications were being taken at the time of the initial examination at the periodontist’s office on 05/2004. The dental history was also unremarkable. There is no family history of similar dental problems within either parent’s background.

Clinical and Radiographic Findings

Dentition is generally healthy.  Plaque control is reasonable. The periodontal health is unremarkable except for a 10+ mm pocket located at the distobuccal of tooth #31, which was found to have subgingival inflammation and suppuration during probing. The contra-lateral tooth # 18 had a 5 – 6 mm probing depth with thickened retro-molar gingiva on the distal root surface.

Radiographically, the lesion between teeth #’s 31 – 32 appears as a narrow, buccal curve along the tooth with an osseous defect and with the developing crown of tooth #32 lying superiorly and horizontally impacted. The lamina dura and the periodontal ligaments around teeth #’s 18 and 31 appear to be intact. No radiographic change was apparent around tooth #18 (Fig 2). Tooth # 31 is vital and responded so endodontically to the application of ice.

Figure 2. Although a 5-6 mm probing depth was detected at the buccal aspect of tooth #18, there are no radiographic changes to correspond to it.

Incisional and Excisional Biopsy

The biopsy specimens showed fragments of loose and vascular granulation tissue covered by proliferative stratified squamous epithelium. The latter contained clusters of neutrophils (Fig 4). The granulation tissue supporting the epithelium was infiltrated by many neutrophils, lymphocytes, plasma cells and foamy macrophages (Fig 5)

Figure 4. Low power (x200) histology shows small fragments of loose and vascular granulation tissue covered by non-keratinized and proliferative stratified squamous epithelium containing small clusters of neutrophils.
Figure 5. Low power (x200) Histology similar to Figure 4 demonstrating a supporting granulation tissue infiltrated by many acute and chronic inflammatory cells.

Differential Diagnosis 1. Mandibular Buccal Infected Cyst (buccal infected cyst) 2. Inflammatory Dentigerous Cyst 3. Lateral Periodontal Cyst 4. Lateral Radicular Cyst

Final Diagnosis See:

Hint: Also called a paradental cyst, and buccal bifurcation cyst