Journal of Oral and Maxillofacial Radiology / January-April 2014 / Vol 2 | Issue 1 30

Pericoronal radiolucency associated with an

impacted premolar tooth
Ulkem Aydin, Ufuk Ates
1
, Burcu Senguven
2

Departments of Dentomaxillofacial Radiology and
1
Oral and Maxillofacial Surgery, Baskent University,
2
Department of Oral Pathology,
Gazi University, Ankara, Turkey
INTRODUCTION
The mandibular second premolar is highly variable
developmentally. Agenesis, abnormal tooth germ position,
and distal inclination of the developing tooth are among the
reported developmental anomalies.
[1-4]
In addition, the second
most frequently impacted tooth was found to be the mandibular
second premolar, excluding third molars, in some populations.
[5]
Treatment options for impacted teeth include observation,
intervention, relocation, and extraction.
[6]
Selection of the
appropriate treatment option depends on the underlying
etiological factors, degree of impaction, position and location
of the impacted tooth, space requirements, need for primary
molar extractions, and root formation of the impacted
premolar. Factors such as the patients medical history, dental
status, oral hygiene, occlusal relationship, and attitude toward
and compliance with treatment will also inuence the choice
of treatment option.
[7]
On the other hand, detection of
pathologic lesions associated with an impacted tooth usually
requires removal of the tooth and the lesion.
[8]
The odontogenic tissue around the impacted teeth
has the propensity to differentiate into a wide variety
of pathological lesions and some of them present as
pericoronal radiolucencies. Among the most frequently
encountered of these is the dentigerous cyst.
[9]
Other
pathologic entities such as dentigerous cyst, odontogenic
keratocyst, unicystic ameloblastoma, and ameloblastic
broma may also present as pericoronal radiolucencies.
[10]

A hamartomatous lesion associated with some impacted
tooth is the hyperplastic dental follicle.
[11]
In some instances
however, enlargement of the pericoronal space can be
detected radiographically but histological examination
does not reveal any pathology. Therefore, biopsy of the
pericoronal follicular tissue is imperative in every case.
[8]
The purpose of the present report was to describe the
radiographic and histopathologic features of a case of
pericoronal radiolucency associated with an impacted
mandibular premolar tooth.
CASE REPORT
A systemically healthy 16-year-old female patient was
admitted to our clinic for a routine check-up. Patient history
A B S T R A C T
The mandibular second premolar is highly variable developmentally. Agenesis, abnormal tooth germ position, distal inclination of
the developing tooth, and impaction are among the reported developmental anomalies. Detection of pathologic lesions associated
with an impacted tooth usually requires removal of the tooth and the lesion. The purpose of the present report was to describe the
radiographic and histopathologic features of a case of pericoronal radiolucency associated with an impacted mandibular premolar tooth.
Key words: Dental anomaly patterns, hyperplastic follicle, impacted tooth
Address for correspondence: Dr. Ulkem Aydin, 11 Sokak No - 26, Bahcelievler, Ankara, Turkey. E-mail: ulkem_aydin@yahoo.com
Case Report
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DOI:
10.4103/2321-3841.133567
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Aydin, et al.: Impacted second premolar
Journal of Oral and Maxillofacial Radiology / January-April 2014 / Vol 2 | Issue 1 31
revealed that she had orthodontic treatment and at that
time, her orthodontist told that she has an impacted tooth.
As the tooth did not interfere with orthodontic treatment
and as she did not have any complaints, extraction was not
recommended at that time. Extraoral examination did not
reveal any abnormality. On intraoral examination, absence
of both mandibular second premolar teeth was evident.
A panoramic radiograph was made in order to evaluate the
impacted tooth and a pericoronal radiolucency associated
with the impacted right mandibular second premolar
tooth was detected. The boundary of the pericoronal
radiolucency was distinct but not corticated, and had a
diameter of approximately 0.5 cm. The impacted tooth
was located horizontally at the level of the roots of the
right mandibular rst molar, rst premolar, and canine
teeth, and distally directed orientation of the tooth crown
was evident [Figure 1].
Review of the patient records revealed that a panoramic
radiograph was made four years ago, just before the
orthodontic treatment, and another one was made two
years ago, during the treatment. The initial radiograph
showed the right mandibular deciduous second molar
tooth, and the incomplete crown of the right mandibular
second premolar tooth that was pointing distally. The
pericoronal space of the tooth was normal. On the left
mandibular side, the second premolar tooth was missing
and the mesial root of the deciduous second molar tooth
was resorbed [Figure 2]. On the panoramic radiograph
made two years ago, the crown formation of the right
mandibular second premolar tooth was almost complete
and a slight enlargement of the follicular space was seen
[Figure 3].
A cone beam computed tomography scan was requested
in order to determine the exact position of the impacted
tooth. Examination of the axial, coronal, and cross-
sectional images revealed that the right mandibular second
molar tooth was obliquely impacted with its crown lingually
and the root buccally at the level of the middle thirds of the
right mandibular rst molar and rst premolar teeth. The
crown of the impacted tooth was neighbouring the mesial
root of the right mandibular rst molar tooth and the
apical portion of the impacted tooth was close to the root
of the right mandibular rst premolar tooth. In addition,
the root of the impacted tooth was in contact with the
superior border of the mandibular canal and the root apex
of the tooth was located just above the mental foramen. A
radiolucent, smooth contoured but uncorticated rounded
lesion with 3.4 mm at its greatest diameter was detected
surrounding the crown of the impacted tooth. The root
formation of the impacted tooth was almost complete but
the apex of the tooth was not closed yet [Figure 4]. The
differential diagnosis was enlarged follicle and dentigerous
cyst. The patient was then referred for surgical operation.
Full thickness mucoperiosteal ap reection on the buccal
and lingual sides and bone exposure was accomplished.
Bone over both the crown and the root apex was removed.
A straight elevator is placed in the groove that was prepared
using a rounded bur and the tooth was removed lingually
through the bone window. Mental nerve and mental
foramen were preserved using a Farabeuf retractor; lingual
ap and lingual nerve were preserved with the help of a
periosteal elevator. Follow-up appointments held one day
Figure 1: Panoramic radiograph revealing the impacted right mandibular
second premolar tooth and the associated pericoronal radiolucency
Figure 2: The initial radiograph showing the incomplete crown of the right
mandibular second premolar tooth and the normal pericoronal space
Figure 3: The panoramic radiograph showing the almost complete crown
of the right mandibular second premolar tooth and a slight enlargement of
the follicular space
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Aydin, et al.: Impacted second premolar
Journal of Oral and Maxillofacial Radiology / January-April 2014 / Vol 2 | Issue 1 32
and 7

days after surgery showed that healing was uneventful
without any neurosensory decit.
On macroscopic examination, the specimen was a soft
tissue material attached to a premolar tooth [Figure 5]. On
hematoxylin and eosin staining, numerous odontogenic
epithelial rests were seen on a mixoid connective tissue that
has a minimal mononuclear inammatory cell inltration
[Figures 6 and 7]. The denitive diagnosis was hyperplastic
dental follicle.
DISCUSSION
Dental anomaly patterns (DAP) are described by Peck
[12]
as
associated dental abnormalities that are observed together
much more frequently than can be explained by chance
alone. Unilateral agenesis of mandibular second premolar,
distal angulation, and delayed development of the unerupted
contralateral second premolar is now considered as one of
these dental anomaly patterns.
[1,4,13]
In the case presented,
all the mentioned features were evident on the panoramic
radiograph made when the patient was 12 years old. Hence,
the case presented is an example of DAP. In addition, the
mesiodistal diameters of the incomplete crowns of the third
molars were shorter than the erupted molars.
One of the treatment options for the management of
mandibular second premolar impaction is to uncover the
tooth surgically and to move it into the arch by orthodontic
treatment.
[6]
In the present case, the need for primary molar
extractions due to the root resorption of the primary left
second molar, agenesis of the left second premolar, and
incomplete root formation of the impacted premolar were
probably the factors that did not permit surgical exposure
and orthodontic alignment of the tooth at the time of
orthodontic treatment.
Observation is another option for the management of
impacted teeth.
[6]
However, our literature research did
not reveal any adopted protocol for the radiographic
assessment of impacted teeth. In the case presented, the
Figure 4: CBCT images. Obliquely impacted tooth with its crown lingually
and the root buccally at the level of the right mandibular rst molar and rst
premolar roots (upper left). Three-dimensional reconstruction showing the
impacted tooth (upper right). The open root apex of the tooth located just
above the mental foramen (lower left). The radiolucent, smooth-contoured but
uncorticated lesion surrounding the crown of the impacted tooth (lower right)
Figure 5: Macroscopic view of the surgical specimen
Figure 6: Fibro-myxoid follicle connective tissue containing hyperplastic
dental epithelium remnants (arrow) (hematoxylene-eosine)
Figure 7: Squamous odontogenic epithelium (large arrow) and abundant number
of epithelial rests in the connective tissue (arrow) (hematoxyleneeosine, x100)
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Aydin, et al.: Impacted second premolar
Journal of Oral and Maxillofacial Radiology / January-April 2014 / Vol 2 | Issue 1 33
patient had an initial panoramic radiograph and another
one made at the end of the orthodontic treatment, made
with two-year interval. Two years later, she admitted to our
clinic for a routine check-up and radiographic examination
revealed the pericoronal radiolucency associated with the
impacted tooth.
Extraction of impacted premolars may be challenging.
Radiographic examination plays a major role in planning the
surgical procedure. Knowing the position of the impacted
tooth is very important in planning the incision.
[7]
In the case
presented, cone beam computed tomography examination
revealed the exact position of the tooth besides close
proximity to the mental foramen and mandibular canal,
and the lingual approach was taken.
When the diameter of a pericoronal space is greater than
2.5 mm on an intraoral radiograph and greater than 3 mm
on a panoramic radiograph, pathosis is suggested, and if the
radiopaque border, representing the surrounding cortical plate,
is not well-dened, this is also a sign of pathologic change.
[9]

The differential diagnosis of pericoronal radiolucencies include
enlarged follicular space, dentigerous cyst, odontogenic
keratocyst, unicystic ameloblastoma, adenomatoid odontogenic
tumor, calcifying cystic odontogenic tumor, and ameloblastic
broma. Other rare lesions such as odontogenic broma,
odontoma in premineralized stage, and odontogenic broma
may also be encountered as pericoronal radiolucencies.
[9,10]

However, the most likely diagnoses include dentigerous cyst,
keratocystic odontogenic tumor (odontogenic keratocyst),
unicystic ameloblastoma, ameloblastic broma, and enlarged
follicular space.
[10]
Keratocystic odontogenic tumor occurs in a wide age
range, but most of them develop during the second and
third decades and has a slight male predominance; more
than half of them are in the ramus region. Although the
lesion may surround the tooth pericoronally, it is connected
to the tooth at a point apical to the cementoenamel
junction.
[10,14]
Therefore, the demographic and radiographic
features of the case presented was not consistent with
odontogenic keratocyst.
Unicystic ameloblastoma is a rare variant of ameloblastoma
and it usually occurs in a young age group, with about half
of the cases occurring in the second decade of life. Most
of them are located in the mandible. Cases associated with
tooth impaction can be encountered, the mandibular third
molar being most often involved.
[15]
Due to the rarity of the
lesion, inconsistency with the usual location, and relatively
younger age of our patient, unicystic ameloblastoma was
not ranked high in the differential diagnosis.
Ameloblastic broma mostly occurs during the period
of tooth formation with an average age of 15 years.
Radiographically, ameloblastic broma usually appears as
unilocular or multilocular radiolucency with well-dened
and corticated borders in the premolar-molar area of
the mandible. The lesion may be located in a follicular
relationship with an unerupted tooth.
[10,16]
Although the
lesion lacks a well-dened and corticated border in the
present case, ameloblastic broma may be included in the
radiographic differential diagnosis.
The dentigerous cyst is the most common pericoronal
radiolucency. The teeth most frequently affected are the
mandibular third molars, the maxillary canines, and the
mandibular premolars.
[9]
The cyst attaches to the crown
of the impacted tooth at the cementoenamel junction.
Dentigerous cysts typically have a well-dened cortex. In
the case presented, the features of the lesion were in line
with the reported characteristics of the dentigerous cyst,
except a well-dened cortex. Regarding the high frequency
of this pathosis associated with impacted teeth, dentigerous
cyst was also considered in the differential diagnosis.
White
[10]
states that one of the most difcult differential
diagnoses to make is between a hyperplastic dental follicle
and a small dentigerous cyst. The size of the pericoronal
radiolucency can be helpful in distinguishing between the
two and if the diameter of the radiolucency exceeds 5 mm,
a dentigerous cyst is more likely.
[9,10]
Hyperplastic dental follicle is an unusual hamartomatous
lesion. The mechanisms causing hyperplastic dental
follicle are not denitively explained. The condition may
involve just one tooth or may be associated with multiple
teeth.
[11]
Downregulation of matrix metalloproteinases
in hyperplastic dental follicles are suggested to result
in abnormal tooth eruption.
[17]
In the present case, the
distal angulation of the tooth seems to be responsible for
impaction of the tooth. Nevertheless, further studies may
be able to shed light on the association of this DAP with
hyperplasia of the dental follicle.
Histopathologically, hyperplastic dental follicle differentiates
from dentigerous cyst with the absence of signicant
lining epithelium. Although surface was partially lined
by single-layered, reduced enamel epithelium in our case,
this feature was not sufcient to diagnose the lesion as a
dentigerous cyst. Odontogenic broma, both WHO type
or simple type, is another lesion to be histopathologically
differentiated from hyperplastic dental follicle. One third of
the odontogenic bromas are associated with an unerupted
tooth. However, there were neither any stellate-shaped
broblasts on connective tissue nor calcicated foci in
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Aydin, et al.: Impacted second premolar
Journal of Oral and Maxillofacial Radiology / January-April 2014 / Vol 2 | Issue 1 34
the case presented. In addition, odontogenic epithelial
rests were not in narrow cord shape as in WHO-type
odontogenic broma in our case.
[18]
In conclusion, awareness of dental anomaly patterns may
change the radiographic interpretation process, diagnosis,
and subsequent treatment planning significantly. The
clinicians should investigate all teeth that fail to erupt at
the expected time, and initiate appropriate assessment and
management of suspected lesions.
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Cite this article as: Aydin U, Ates U, Senguven B. Pericoronal radiolucency
associated with an impacted premolar tooth. J Oral Maxillofac Radiol
2014;2:30-4.
Source of Support: Nil. Conict of Interest: None declared.
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