|Year : 2019 | Volume
| Issue : 1 | Page : 45-48
Management of impacted transmigrated mandibular canine associated with dentigerous cyst: A surgical approach
Akhilesh Kumar Singh1, Naresh Kumar Sharma1, Nitesh Mishra1, Shankar Singh1, Shreya Singh2
1 Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Orthodontics and Dentofacial Orthopaedics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
|Date of Web Publication||17-May-2019|
Dr. Akhilesh Kumar Singh
Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Transmigration of impacted canine is an uncommon phenomenon in which unerupted canine crosses the midline. Sometimes, this condition may also be associated with any pathology or cystic degeneration, and in such a case surgical extraction along with the enucleation of cyst is the preferred treatment modality. The present study discusses a case of a 12-year-old adolescent male with similar condition managed with surgical removal of tooth and cyst enucleation.
Keywords: Dentigerous cyst, impacted canine, mandibular canine, transmigration
|How to cite this article:|
Singh AK, Sharma NK, Mishra N, Singh S, Singh S. Management of impacted transmigrated mandibular canine associated with dentigerous cyst: A surgical approach. Int J Oral Health Sci 2019;9:45-8
|How to cite this URL:|
Singh AK, Sharma NK, Mishra N, Singh S, Singh S. Management of impacted transmigrated mandibular canine associated with dentigerous cyst: A surgical approach. Int J Oral Health Sci [serial online] 2019 [cited 2019 Dec 13];9:45-8. Available from: http://www.ijohsjournal.org/text.asp?2019/9/1/45/258576
| Introduction|| |
Transmigration is an uncommon phenomenon in which unerupted tooth crosses the midline. Ando et al. first uses the term “Transmigration.” Transmigration is generally found in mandibular canines but may occur rarely in maxillary canine. Transmigrated canines usually remain asymptomatic, though follicular cyst formation and chronic infection with fistula formation may occur., They may remain impacted or erupt ectopically. In some cases, transmigrating teeth may cause pressure resorption of roots or tilting of teeth. Transmigrated mandibular canine mostly occurs unilaterally, but some cases of bilateral occurrence also had been reported. It is more frequently found in females as compared to that of males in the ratio of 1.6:1., Due to its unfavorable position, repositioning by orthodontic means is rarely indicated, and since transmigrated mandibular canine may also develop pathology associated with it, transalveolar extraction is mostly indicated.
| Case Report|| |
A 12-year-old adolescent male reported with a chief complaint of malaligned lower front teeth. Intraoral examination revealed retained right deciduous mandibular canine and absence of right mandibular permanent canine [Figure 1]. Orthopantamogram and lateral cephalogram showed a horizontally placed impacted mandibular canine of the right side crossing the midline with well-defined radiolucency surrounding the coronal portion [Figure 2] and [Figure 3]. The location of impacted canine was just above the inferior border of mandible crossing the midline up to the level of contralateral canine. By analyzing all the clinical and radiological findings, a provisional diagnosis of dentigerous cyst associated with transmigrated impacted right mandibular canine is established. Orthodontic consultation was done regarding retrieval but denied by the specialists. The patient was counseled about the treatment and complications. After routine blood investigations, the patient was planned for transalveolar extraction along with enucleation of cyst through crevicular approach under local anesthesia. After preoperative preparation, local anaesthesia with injection lignocaine 2% solution was applied over bilateral inferior alveolar nerve. The crevicular incision with vertical releasing was made from left mandibular canine to right mandibular canine for adequate exposure. On exposing the lesion, a hard dome-shaped bony enlargement was observed over the symphysis region [Figure 4]. The overlying bone was removed and crown exposed [Figure 5], and then the canine was removed in two pieces after tooth sectioning. The residual cystic lining was also enucleated [Figure 6]. Curettage of the remaining cavity was further done. Soft-tissue closure was achieved in single layer with 3–0 silk suture [Figure 7]. Photomicrograph shows a section stained with H and E which reveals the presence of cystic cavity lined by nonkeratinized squamous epithelium overlying the fibrous connective tissue stroma [Figure 8]. The postoperative healing was uneventful. The patient is regular to follow-up for the past 6 months.
|Figure 1: Intraoral photograph showing crowding of mandibular anterior teeth and retained deciduous right mandibular canine|
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|Figure 2: Orthopantomogram showing horizontally placed transmigrated impacted mandibular right canine with well-defined radiolucency around the coronal portion of canine suggestive of dentigerous cyst|
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|Figure 3: Lateral cephalogram showing impacted tooth near the inferior border of the mandible|
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|Figure 8: Photomicrograph shows a section stained with H and E which reveals the presence of cystic cavity lined by nonkeratinized squamous epithelium overlying the fibrous connective tissue stroma|
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| Discussion|| |
Transmigration of canine is an uncommon phenomenon affecting mostly left side of the mandible with its incidence higher in females. Tarsitano et al. defined transmigration as a phenomenon in which an unerupted mandibular canine migrates, crossing the midline. Kuftinee expanded the definition to include the cases in which more than half of the tooth had passed through the midline. Joshi and Auluck et al. suggested that the tendency of canine to cross the midline suture is an important consideration than the actual distance of migration after crossing the midline., Little is known about the etiology of transmigration; however, various etiologies are suggested such as premature loss or retention of deciduous canines, long path of eruption of canine, trauma, tumors, odontomas, no anatomical restriction in the midline of the mandible, and genetic predisposition. Marks and Schroeder suggested that a regional disturbance in the dental follicle might lead to local defective osteoclastic function with an abnormal eruption pathway being formed. Virchi and Franchi suggested that proclination of lower incisors, increased axial inclination of the unerupted canine, and an enlarged symphyseal cross-sectional area of the chin may be favorable conditions for transmigration.
Clinical findings associated with transmigration of the canines include the absence of mandibular canines in the dental arch or abnormal retention of the mandibular primary canine. A few cases also involved congenitally missing mandibular lateral incisors and mandibular premolars. Transmigration is mainly diagnosed with the help of radiographic evaluation, which is primarily based on the panoramic radiograph. Mostly transmigrated canines are asymptomatic, although follicular cyst formation and chronic infection with fistula formation have been reported. The following criteria were used to describe transmigration patterns: inclination of the long axis of the canine; the relationship of the canine; and, in particular, the crown with the midline, adjacent teeth, and contralateral erupted canine. The transmigrated teeth were classified based on their migratory pattern and the final position within the jaw when diagnosed.
Type 1: Canine positioned mesioangularly across the midline within the jaw bone, labial or lingual to anterior teeth, and the crown portion of the tooth crossing the midline
- Type 2: Canine horizontally impacted near the inferior border of the mandible below the apices of the incisors
- Type 3: Canine erupting either mesial or distal to the opposite canine
- Type 4: Canine horizontally impacted near the inferior border of the mandible below the apices of either premolars or molars on the opposite side
- Type 5: Canine positioned vertically in the midline (the long axis of the tooth crossing the midline) irrespective of eruption status.
According to above-mentioned classification, our case shows “Type 2” pattern of transmigration. Surgical removal, transplantation, radiographic follow-up, and surgical exposure with orthodontic treatment are suggested treatment options. Here, surgical extraction is the treatment of choice, keeping in mind the position of nerve and position of root apices with respect to transmigrated mandibular canine. It should also be noted that innervations of transmigrated canines are from the original side. Hence, anesthesia of the originating side is essential during surgical treatment.
| Conclusion|| |
The presence of an over-retained mandibular canine should always be investigated both clinically and radiographically to rule out the condition. Many treatment modalities have been suggested, but when transmigrated canine is associated with a pathologic or any cystic degeneration, surgical management is one of the most favored treatments in literature.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]