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Case Report
Paradental cyst of the first molar: Report of
a rare case with bilateral presentation and
review of the literature
Abstract
The paradental cyst is a lesion classified and recognized by
World Health Organization quite recently, which is related
to an inflammatory process, especially pericoronitis, involving
a tooth in eruption. The aim of this article is to report a rare
bilateral case of paradental cyst. An 8‑year‑old boy presented
to the Oral Surgery Department, Dental Clinic, Istituto di
Ricerca e Cura a Carattere Scientifico (IRCCS) Fondazione
Ospedale Maggiore Policlinico, University of Milan, with
the complaint of swelling over the buccal gingiva of his
unerupted lower left first molar. Radiographs revealed a
radiolucency involving the bifurcation and root area of
teeth 36 and 46. The cysts were enucleated, maintaining
the affected teeth in site; microscopic evaluation revealed a
chronically inflamed cyst lined by a non‑keratinized stratified
squamous epithelium; the histopathology associated with
macroscopic and radiographic examinations permitted the
definitive diagnosis of a paradental cyst on the mandibular
left and right first molars. The most recent literature shows
the rarity of the paradental cyst occurring with bilateral
localization. Because the paradental cyst can present variable
clinical and radiographic signs, it is mandatory to correlate
all clinical, radiographic, and histological data to obtain a
definitive diagnosis.
Key words
Bilateral cyst, mandibular disease, oral surgery, paradental cyst
Introduction
The first clinical and histological description of a
paradental cyst was reported by Main[1] in 1970. The
condition was initially described as an inflammatory
collateral cyst, but the diagnosis has caused many
controversies in the literature. The current nomenclature
was suggested by Craig[2] in 1976.
JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Oct - Dec 2012 | Issue 4 | Vol 30 |
Borgonovo AE, Reo P, Grossi GB, Maiorana C
Department of Oral Surgery, University of Milan, Fondazione
IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
Correspondence:
Dr. Pietro Reo, Via Wildt 14, 20131 Milan, Italy.
E‑mail: pietroreo@hotmail.com
Access this article online
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DOI:
10.4103/0970-4388.108940
PMID:
***
According to the World Health Organization (WHO)
histological typing of odontogenic tumors, the
paradental cyst is defined as “a cyst occurring near
to the cervical margin of the lateral aspect of a root
as a consequence of an inflammatory process in a
periodontal pocket. A distinctive form of the paradental
cyst occurs on the buccal and distal aspects of erupted
mandibular molars, most commonly the third molars,
where there is an associated history of pericoronitis.”[3]
The etiology of these cysts is still debated, but it
is believed that they originate from the reduced
epithelium of enamel[2,4] or from the inflammatory
proliferation of epithelial rests of Malassez [5,6]
that come from the superficial mucosa of a tooth in
eruption (pericoronitis).[3] They represent beyond 5%
of all odontogenic cysts.[2,7]
The major clinical feature of the paradental cyst is
the presence of a recurring inflammatory periodontal
process, usually a pericoronitis. Apart from acute
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Borgonovo, et al.: Bilateral paradental cyst of the first molar

episodes, this cyst presents only a few signs and mild and then enucleated trough the access previously
symptoms, including discomfort, tenderness, moderate created [Figure 5]. Having done an irrigation with
pain, and in some cases, suppuration through the sterile saline, the suture was carried out with silk 4/0.
periodontal sulcus.[8‑10]
Histologically, the cyst capsule was lined by a
The aim of this work is to present a rare case of bilateral proliferating, non‑keratinized, stratified squamous
paradental cyst in a young patient affecting the buccal epithelium, showing as arcading. The cystic wall
aspect of lower first molars, discussing diagnosis, consisted of a dense, mature fibrous connective tissue,
treatment, and radiographic findings of the case. with an intense chronic inflammatory reaction mainly
near the epithelium [Figure 6].
Case Report
An 8‑year‑old boy was referred to Oral Surgery
Department, Dental Clinic, IRCCS Fondazione
Ospedale Maggiore Policlinico, University of Milan,
Italy, with the complaint of swelling over the buccal
gingiva of his unerupted lower left first molar. Clinically,
there was mild edema in the overlaying mucosa distal
to the second deciduous molar, showing a bluish
color [Figure 1]. The evaluation of the panoramic
radiography [Figure 2] disclosed a well‑defined
semilunar‑shaped radiolucency, demarcated by a fine
radiopaque line, on the buccal aspect of the unerupted Figure 1: Intraoral pre‑operative view – left side
lower left first molar [Figure 3]. Observing closely the
radiograph, a second lesion was evident on the buccal
aspect of the partially erupted right lower first molar,
but less defined than the previous.

Computed tomography showed and confirmed

the presence of bilateral lesions to the lower first
molars [Figures 4]; in both cases, the margins of
radiolucent lesions were delimited by a thin layer of
denser bone on the buccal aspects, revealing the presence
of the cysts and their relations to both first and right
lower first molars; the cysts were extended from the
cement–enamel junction to the lower root margins, Figure 2: Panoramic radiograph shows a well‑defined semilunar‑shaped
radiolucency, demarcated by a fine radiopaque line on the buccal
measuring about 10 mm in the largest extension. aspect of the left and right lower first molars

Electric pulp test for left lower first molar, partially

erupted, was positive.
Clinical, radiographic, and anamnestic findings
suggested an initial diagnosis of paradental cyst.
We decided for a surgical removal of the cysts under
general anesthesia, planning to maintain the affected
teeth.
The surgical approach was a full‑thickness trapezoidal
flap, with gingival crevicular incision and vertical
releasing incisions; buccal ostectomy was done, care
was taken to preserve a sufficient band of cortical bone
in the coronal aspect. The cysts have been exposed Figure 3: Intraoral pre‑operative view – right side

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Borgonovo, et al.: Bilateral paradental cyst of the first molar

The histopathology associated with macroscopic and about 1 year after surgery, evidence the complete
radiographic examinations permitted the definitive regression of the lesion and the correct eruption
diagnosis of a paradental cyst on the mandibular left of the mandibular permanent left and right first
and right first molars. molars [Figures 7‑8].

Follow‑up is still ongoing, but the panoramic Discussion

radiography and clinical examinations, performed
An inflammatory etiopathogenic nature of paradental
cysts has been widely discussed in the literature. Initially,

Figures 5: Intraoperative view of the enucleation of the two cysts

Figure 6: Histopathological analysis of the two cysts

Figures 4: Computed tomography shows that the margins of Figure 7: Panoramic radiograph  1  year after surgery, indicating a
radiolucent lesion were delimited by a thin layer of denser bone on complete regression of the two lesions and the correct eruption of the
the buccal aspect mandibular left and right first molars

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Borgonovo, et al.: Bilateral paradental cyst of the first molar
Figures 8: Intraoral view 1 year after surgery, showing the correct
eruption of mandibular left and right first molars
all reported cysts involved lower third molars with
inflammatory processes[11] and when the lower first
permanent molars of children aged between 6 years and
8 years were involved, these cysts were called mandibular
infected buccal cysts.[12] This type of cystic lesion was
considered a distinct clinical entity by some authors,[4,13]
but this concept was never fully accepted.[11]
The paradental cyst is considered a rare lesion; it
was included in the WHO histological typing of
odontogenic tumors for the first time in 1992, although
it has been described in several clinicopathological
studies in specialized journals since 1970.[1,2,5,6] The
relatively recent characterization of this cyst can be a
contributing factor to its non‑recognition; on the other
hand, it has been speculated that this lesion has been
underdiagnosed. Lindh and Larsson[14] believe that the
paradental cyst has been misdiagnosed as a dentigerous
cyst, lateral radicular cyst, or merely as pericoronitis or
some other entity related to inflammatory conditions
of the dental follicle. Another fact that could result
in the underdiagnosis of paradental cysts is that
histopathological analysis of extirpated follicular sacs
is rarely done.
The prevalence of paradental cysts is low compared
to other cysts, representing 3‑5% of all odontogenic
cysts.[4,5,12,15] In the mandible, this lesion was detected
in only 26 (0.9%) of the 2700 cyst cases studied by
Magnusson and Borrman,[16] who ascribed the low
prevalence to several possible misdiagnoses. Specifically
in regard to the lower third molars, this can be
considered the second most frequent cyst, representing
up to 25% of the cystic lesions associated with these
teeth, although they represented only 1.6% of the cystic
lesions analyzed by Colgan et al.[4]
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The paradental cyst is localized exclusively in the
mandibular region, almost always on the distal or
vestibular side of a completely or partially erupted
molar, but always vital. Although the mesial surface
could be involved very rarely,[5,9] the lingual aspect
is never interested. More than 60% of the cases of
paradental cysts are associated with the lower third
molars.[9]
Since the radiological 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,”[1] 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 second molar appear between
13 years 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 onset 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.[17]
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, as described by
Stoneman et al.[10]
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.[2,6]
The medium age of the patients with paradental cysts
localized at the lower third molar is approximately
25‑30  years, with a distal or disto‑vestibular localization
to the affected tooth; bilateral localizations are marked
just in 4.1% of the cases.[9] In these cases of paradental
cyst, usually a history of recurrent pericoronitis
is reported and there is often the presence of a
communication between the periodontal pocket and
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Borgonovo, et al.: Bilateral paradental cyst of the first molar
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.[18]
The etiology of paradental cysts is of an inflammatory
nature, as shown by the histological findings of
odontogenic epithelium proliferation, presence of
an inflammatory infiltrate, and occasional hyaline
changes in blood vessel walls.[4,13,15‑17] However, there
are controversies surrounding the origin of the lining
epithelium. According to Souza et al.,[15] most cases of
paradental cysts stem from the proliferation of reduced
epithelium of the enamel organ, probably caused by
inflammatory stimuli originating from the junction of
the epithelium of the cystic capsule with the gingival
epithelium. Colgan et al.[4] and Lim and Peck[17] also
believe that this cyst arises from reduced epithelium of
the enamel organ. The epithelial remnants of Malassez
seem to be the most unlikely origin, although they may
unreasonably explain cysts located near the roots.[15]
In this article, the authors present a case of bilateral
paradental cyst involving both the left and right
mandibular first molar. In both cases, the radiographic
image of these lesions revealed a well‑defined
radiolucency associated with the roots on their buccal
aspect.
The differential diagnosis included the radicular cyst,
odontogenic keratocyst, lateral periodontal cyst,
gingival cyst, dental follicles, and the dentigerous cyst.
The most recent literature shows the rarity of the
paradental cyst occurring with bilateral localization;
some authors[17] report only seven cases of bilateral
involvement, including lesions occurring on first,
second, and third molars; a more detailed analysis on
342 cases carried out by Philipsen et al.[9] reveals only
23.6% of bilateral occurrence for paradental cysts on
first and second mandibular molars and 4.1% for those
involving third molars. Considering the low prevalence
of the paradental cyst (3‑5% of all odontogenic cysts),
we can assert that the bilateral occurrence is very rare.
In our case, the second lesion on the right side
was noted on radiographs (and confirmed only by
computed tomography); for this reason, it is generally
recommended that the contra‑lateral tooth should be
carefully evaluated for a second lesion.
Most studies[5,6,10,19,20] report that a positive electric
JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Oct - Dec 2012 | Issue 4 | Vol 30 |
pulp test is a diagnostic criterion for paradental cyst.
The diagnosis would be a lateral radicular cyst if the
associated tooth is non‑vital.[21]
The initial diagnosis of paradental cyst was made
considering the anamnestic, clinical, and radiological
features. Only the enucleation of cyst without
extraction of the adjacent tooth was done in both
the cysts. Most reports[5,11,20‑22] 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, whereas surgical removal of
the tooth and the paradental cyst has been considered
the best case solution when the involved tooth is
a third molar. [8,9,21] Pompura et  al. [23] presented
44 cases treated by enucleation without extraction.
Packota et  al.[11] 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,[20] 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[21] series involving the mandibular
first and second molars, 11 of the 13 cases treated
with preservation of the involved tooth had successful
outcome. In all cases, recurrence is rare, provided that
the lesion has been completely removed.[6,21,23‑25]
The histopathological features of the paradental cyst
are identical to the radicular cyst and to those of
other inflammatory odontogenic cysts; microscopic
examination shows a fibrous connective tissue capsule
invaded by a lymphocytic inflammatory infiltrate, lined
by a hyperplastic, non‑keratinized, stratified squamous
epithelium; in the case that we described, both the cysts
capsule were lined by a proliferating, non‑keratinized,
stratified squamous epithelium, showing as arcading.
The cystic wall consisted of a dense, mature fibrous
connective tissue, with an intense chronic inflammatory
reaction mainly near the epithelium, supporting a
definitive diagnosis of a paradental cyst.
The paradental cyst can present variable clinical and
radiographic signs,[2] in addition to being confounded
with the radicular cyst at the microscopic level; for
these reasons, it is mandatory to correlate all clinical,
radiographic, and histological data to obtain a definitive
diagnosis. Surgical findings, such as bony cavitation,
cystic content, and location of lesion adherence,
can give some important clues. Enucleation of the
lesion with the maintenance of the associated tooth
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Borgonovo, et al.: Bilateral paradental cyst of the first molar
can be indicated when the first or second molars are
involved.[8,9,11,19,26]
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How to cite this article: Borgonovo AE, Reo P, Grossi GB,
Maiorana C. Paradental cyst of the first molar: Report of a rare
case with bilateral presentation and review of the literature. J
Indian Soc Pedod Prev Dent 2012;30:343-8.
Source of Support: Nil, Conflict of Interest: None declared.