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CASE REPORT

Paradental cyst of the first molar: A report of

two cases
Borgonovo AE, Speroni S, Fabbri A, Grossi GB

Abstract
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.

Key words
Paradental cyst Mandibular disease Children Odontogenic cyst
DOI: 10.4103/0970-4388.66753

PMID: ****

Introduction

Correspondence:
Dr. Alberto Fabbri, Via primavera n1, 28925 Verbania (VB),
Italy. E-mail: alberto.fabbri@libero.it

The etiology of these cysts is still debated, but it is

believed that they originate from the reduced epithelium
of enamel[1,2] or from the inflammatory proliferation
of epithelial rests of Malassez[3,4] that come from the
superficial mucosa of a tooth in eruption (pericoronitis).[5]
They represent beyond 5% of all odontogenic cysts.[1,6]
Some cases of paradental cyst are asymptomatic and
are diagnosed incidentally from a radiograph,[7] whereas
others remain undetected by clinical examination and
radiograph.[1]
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.[8-10]
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.

Case Reports

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.
116

Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico

Milano, Universit degli Studi di Milano, Milan, Italy

Case 1
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

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Borgonovo, et al.: Paradental cyst of the first molar

Figure 1: Panoramic radiograph reveals radiolucency, demarcated

by a fine radiopaque line situated around the roots of the mandibular
left first molar

Figure 2: Computed tomography showing that the margins of

radiolucent lesion were delimited by a thin layer of denser bone on
the buccal aspect

Figure 3: Intraoperative view of the enucleation of the cyst; the

extraction of the left first mandibular molar was not necessary

Figure 4: Panoramic radiograph performed after 6 months that

evidenced complete regression of the lesion and the correct eruption
of the mandibular permanent left first molar

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
inflammator y 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

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Borgonovo, et al.: Paradental cyst of the first molar

Figure 5: Panoramic radiograph showing a well-defined ovoid

radiolucency on the buccal aspect and extending apically on the
mandibular left first molar

Figure 6: Computed tomography showing the presence of the cyst

and its relation to the molar; there was an expansion of cortical bone
with a peripheral sclerotic border

Figure 8: Panoramic radiograph performed 1 year after the enucleation

showing a complete bone regeneration and the complete euption of
the tooth

Figure 7: Intraoperative view of the enucleation of the cyst

months after surgery.

Case 2
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 15 mm and involved the
mesial and distal roots; it was surrounded by a sclerotic
margin [Figure 5]. Computed tomography showed the
118

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

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Borgonovo, et al.: Paradental cyst of the first molar

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].

Discussion
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.[1,3,4,11] Most
cases described in literature till date have occurred
in mandibular third molars, and less frequently
in second[12,13] and first molars,[14-18] and rarely in
premolars[19] or incisors/canines.[11]
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,[3,9] the lingual aspect
is never interested . Beyond 60% of the cases of
paradental cysts are associated with the lower third
molars.[9]
Since the radiologic features are different according to
the tooth involved,[9] we can distinguish the paradental
cysts developed on the first and second inferior molars,
also called as juvenile paradental cysts,[11] from those
involving the inferior third molar.
The medium age of the patients with paradental cyst
localized at the lower first molar is 89 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.[9]
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.[9]
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.[12]
According to Stoneman et al.,[10] 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
2530 years, and bilateral localizations are marked just
in 4.1% of the cases.[9] 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.[20]
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[3,10,13,21,22] 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.[7] 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[3,14,16,21,23] 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

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Borgonovo, et al.: Paradental cyst of the first molar

al.[24] presented 44 cases treated by enucleation without

extraction. Packota et al.[16] successfully treated five
cases of paradental cyst involving the mandibular first
molar with enucleation of the cyst without extraction.
In Wolf and Hietanens report,[21] 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 Praetoriuss[23] series involving the
mandibular first and second molars, 11 of the 13 cases
treated with preservation of the involved tooth had
successful outcome.

6.

Histologic features of paradental cyst are similar

to those of other inflammatory odontogenic cysts.
[1,10,16,21,25]
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.

12.

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.

2.
3.
4.
5.

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Kramer IRH, Pindborg JJ, Shear MH. Histological typing of
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Source of Support: Nil, Conflict of Interest: Nil

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