The Journal of Craniofacial Surgery & Volume 25, Number 3, May 2014
8. Shah JP, Haribhaki V, Loree TR, et al. Complications of the pectoralis
major myocutaneous flap in head and neck reconstruction. Am J Surg
1990;160:352Y355
9. Mehrof AI, Rosenstock A, Neifeld JP, et al. The pectoralis major
myocutaneous flap in head and neck reconstruction. Am J Surg
1983;146:478Y480
10. Baek SM, Lawson W, Biller HF. An analysis of 133 pectoralis major
myocutaneous flaps. Plast Reconstr Surg 1982;69:460Y465
A Clinicoradiographic and
Pathological Study of
Pericoronal Follicles Associated
to Mandibular Third Molars
Fábio Wildson Gurgel Costa, DDS, PhD,*
Thales Salles Angelim Viana, DDS,Þ
Galyléia Meneses Cavalcante, DDS,Þ
Paulo Goberlânio de Barros Silva, DDS,Þ
Roberta Barroso Cavalcante, DDS, PhD,þ
Alexandre Simões Nogueira, DDS, MSc,§
Karuza Maria Alves Pereira, DDS, PhD,§
Background: Third molar surgery is considered the most frequently
performed procedure in oral surgery. Although there are some in-
dications for the removal of this tooth, such as the possibility of
cystic degeneration or a tumor of the adjacent pericoronal follicle,
there is no consensus in the literature about their prophylactic removal.
Objectives: The aims of this study were to investigate the patho-
logical alterations related to mandibular third molar dental follicles
and to perform a narrative literature review.
Methods: A prospective clinical, radiographic, and histopathologic
study was conducted with pericoronal follicles of third molars. After
histopathologic evaluation and establishment of diagnosis, 2 groups
were defined: G1 (pericoronal tissues with pathological alterations
based on histopathologic analysis) and G2 (pericoronal tissues
without pathological alterations based on histopathologic analysis).
In addition, a systematic review of the literature was performed.
Results: One hundred thirteen specimens were analyzed. G1 was the
most prevalent (P = 0.0004). Lesions were found in patients between
20 and 25 years of age (P < 0.004). The most prevalent histological
diagnosis was the paradental cyst (47.7%; P < 0.0001). The narrative
literature review showed that the majority of cases were mainly
dentigerous cysts (P < 0.05).
Conclusions: The mandibular third molars in young adults showed
a direct relationship with age and a statistical propensity for the
development of these cystic alterations, notably paradental cysts.
From the *Oral Radiology Department and †Stomatology Department,
School of Dentistry, Federal University of Ceará; and ‡Oral Pathology
Department, School of Dentistry, Fortaleza University, Fortaleza; and
§Stomatology and Oral Pathology Department, School of Dentistry,
Federal University of Ceará, Campus Sobral, Ceará, Brazil.
Received November 30, 2013.
Accepted for publication January 6, 2014.
Address correspondence and reprint requests to Fábio Wildson Gurgel Costa,
DDS, PhD, Rua João Sorongo, 1016, apto. 205, Jardim América; CEP
60416-000, Fortaleza-Ce, Brazil; E-mail: fwildson@yahoo.com.br
No funding was received for this study.
The authors report no conlficts of interest.
Copyright * 2014 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000000712
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
Key Words: Third molar, pathology, pericoronal follicles, parade-
ntal cysts
T hird molar (3M) surgery is considered the most frequently per-
formed procedure in oral surgery.1,2 Although there are some in-
dications for the removal of this tooth, such as the possibility of cystic
degeneration or a tumor of the adjacent pericoronal follicle, there is
no consensus in the literature about their prophylactic removal.3
Thus, this research aimed to conduct a prospective clinicoradiographic
and pathological study of pericoronal follicles associated to man-
dibular 3Ms in a Brazilian population and to perform a narrative
literature review to compare the results of this study with previously
published data.
METHODS AND MATERIALS
A prospective study was conducted in which clinical, radiographic,
and histopathologic data were collected from patients who pre-
sented at the dental specialties clinic ‘‘Centro de Especialidades
Odontológicas Sanitarista Sérgio Arouca’’ in Sobral, Brazil, for the
surgical removal of 3Ms between March 2007 and August 2011.
Patients who had undergone at least 1 surgery for removal of man-
dibular 3Ms were included in the current study. Patients were excluded
from the study when their reports referred to pathologies associated
with other teeth or when the information contained in the reports was
incomplete. This study was approved by the Ethics Committee of the
Universidade Vale do Acaraú, Sobral, Brazil (protocol 1018/11). All
patients sent the term of consent signed.
The data were analyzed according to sex, age, histopathologic
type, degree of dental eruption (erupted, partially erupted, and
nonerupted), angulation, and radiographic and macroscopic size.
A researcher who was blind to the group to which the analyzed
radiograph belonged measured the radiographic size of the radio-
lucent area around the 3Ms. For this purpose, measurement was
standardized as follows: the pericoronal radiolucency was measured
by means of an endodontic millimeter ruler (Golgran, Brası́lia,
Federal District, Brazil) on a negatoscope, tracing a straight line par-
allel to the occlusal surface of the tooth along its longest mesiodistal
axis on the crown. The diameter of the radiolucency was measured by
the following formula: longest diameter of radiolucency = longest
diameter between the mesial face of the tooth and the end of the
radiolucent area j longest coronal diameter between the mesial and
distal faces of the tooth (Fig. 1). The macroscopic size of the tissue
was collected according to its largest size as shown on the anatomo-
pathological report. The histopathologic diagnosis was established in
accordance with the most recent World Health Organization criteria.4,5
The histopathologic characteristics of the paradental (pathological cavity
lined by a hyperplastic epithelium and the presence of intense chronic
inflammation) and dentigerous cysts (thin fibrous cystic wall lined
by 2- to 3-layer-thick stratified nonkeratinizing squamous epithe-
lium and the presence of scarce inflammatory infiltration in the
cellular connective tissue) are illustrated in Figures 2 and 3, re-
spectively.4,5 After histopathologic evaluation and establishment of
diagnosis, 2 groups were defined: G1 (pericoronal tissues with
pathological alterations based on histopathologic analysis) and G2
(pericoronal tissues without pathological alterations based on his-
topathologic analysis).
In addition, a narrative literature review was conducted to com-
pare the presented sample with previously published studies. The
search strategy was applied in the PubMed, MEDLINE and LILACS
databases with the keywords ‘‘third molar,’’ ‘‘dental follicle,’’ and
‘‘pathology.’’ The search resulted in an initial sample of 221 scien-
tific articles. After an initial refinement, only 34 articles remained;
e283
Brief Clinical Studies The Journal of Craniofacial Surgery & Volume 25, Number 3, May 2014

FIGURE 1. A, Radiographic appearance of a pericoronal radiolucency. B,

Schematic image of the methodology for assessing the size of the radiolucency
of the processes associated with lower 3Ms.
187 articles were excluded after reading the titles because they did
not coincide with the subject matter. After further filtering, 23 ar-
ticles were excluded because they did not meet the inclusion criteria;
thus, only 11 articles were selected for detailed analysis. The eligi-
bility criteria included articles that consisted of a histopathologic
investigation and were written in English, Portuguese, or Spanish in
the period from 1999 to 2012. Articles related to other teeth, liter-
ature reviews, case reports, editorials, and radiographic research
without histopathologic proof were excluded.
The data were analyzed with the aid of the BioEstat 5.0 program
(Institute for Sustainable Development Mamirauá, Ministry of Sci-
ence, Brazil), and the nominal qualitative variables were expressed
as absolute frequencies and were analyzed using the W2 test or Fisher
exact test. The prevalence rates for each study were individually
compared with those of the current study by calculating the esti-
mated difference in proportions. In all the cases, the probability >
was established at 5%, and P < 0.05 (2 tailed) was considered to be
statistically significant.
RESULTS
General Results
The final sample was composed of 113 pericoronal follicles surgi-
cally removed from 104 patients (ratio of number of surgical spec-
imens: number of patients = 1.09:1.00). Of these, 42 were pertained
to males (37.1%), versus 71 (62.9%) from females (P = 0.0603). The
ages ranged from 13 to 71 years, with a mean age of 24 years. The
most prevalent age range was between 20 and 25 years of age (P =
0.0017). With regard to the degree of impaction, 79 teeth were
partially erupted, and 20 were nonerupted (P < 0.0001). Radio-
graphically, the sizes ranged between 0.50 and 45.00 mm (mean,
2.97 mm). G1 was the most prevalent (n = 83; 73.4%) between the
groups, presenting a statistically significant difference in compari-
son with G2 (P = 0.0004; Table 1).
FIGURE 3. Dentigerous cyst. Photomicrograph showing a thin fibrous cystic
wall lined by 2- to 3-layer-thick stratified nonkeratinizing squamous epithelium
and the presence of scarce inflammatory infiltration in the cellular connective
tissue (hematoxyln-eosin stain, original magnification 400).
cyst (n = 55; 66.2%), followed by the dentigerous cyst (n = 21;
25.3%). Seven samples (8.5%) were not conclusively diagnosed.
The majority of the teeth were partially erupted (P < 0.0001; Table 1).
Radiographically, the pericoronal radiolucent areas ranged between
0.50 and 45.00 mm in diameter (mean, 3.23 mm). The radiographic
examination revealed lesions that were smaller than 2 mm (n = 25;
30.1%), with no statistical significance. Macroscopically, the surgical
tissues ranged between 0.40 and 3.50 cm (mean, 1.49 cm). The
majority of the tissues were of a macroscopic size smaller than 2 cm
(n = 55; 66.2%) (Table 2).
G2VThird Molars Without Associated
Pathological Lesions
This group was composed of 30 specimens from 26 patients, of
which 22 pertained to female (mean age, 22.1 years) and 8 were
male (mean age, 23.6 years). The patients’ ages ranged from 13 to 38
years (mean, 22.50 years). With respect to the radiographic position,
13 teeth (43.3%) were nonerupted, and 10 teeth (33.3%) partially
erupted. Radiographically, the size of the dental follicle space ranged
from 0.50 to 7.00 mm (mean, 2.21 mm). Ten teeth were of less than
2.00 mm (n = 10; 33.3%). Macroscopically, the surgical tissues
ranged between 0.50 and 2.30 cm (mean, 1.38 cm). The majority of
the tissues were of a macroscopic size smaller than 2.00 cm (n = 22;
73.3%). There was no statistically significant difference in the
comparison with G1 (P= 0.8140) (Table 2).
Literature Review
Initially, a total of 3675 specimens were obtained from 8344 pa-
tients (Table 3). Because of the absence of data in 2 studies,6,7

G1VThird Molars With Associated Pathological TABLE 1. Distribution of the Groups According to Sex, Age Range (in Years),
and Degree of Dental Eruption (n = 113)
Lesions
Group 1 Group 2 Total
This group consisted of 83 specimens from 78 patients, of which
Variables (n = 83) (n = 30) P* (n = 113) P*
59% pertained to female, with an age range between 13 and 71 years
(mean, 24.66 years) (Table 1). The peak age in this group was Sex
between 20 and 25 years, with 49 specimens (59%) identified. The Male 34 (40.96%) 8 (26.67%) 0.1914 42 (37.17%) 0.0603
most frequently identified pathological alteration was the paradental Female 49 (59.04%) 22 (73.33%) 71 (62.83%)
Age range, y
<20 11 (13.25%) 9 (30%) 0.1191 20 (17.70%) 0.0017
|20Y25| 49 (59.04%) 14 (46.67%) 63 (55.75%)
>25 23 (27.71%) 7 (23.33%) 30 (26.55%)
Degree of
dental eruption
Erupted 2 (2.41%) 2 (6.67%) <0.0001 4 (3.54%) <0.0001
Partially erupted 69 (83.13%) 10 (33.33%) 79 (69.91%)
Nonerupted 7 (8.43%) 13 (43.33%) 20 (17.70%)
Not informed 5 (6.03%) 5 (16.67%) 10 (8.85%)
FIGURE 2. Paradental cyst. Photomicrograph showing a pathological cavity
lined by a hyperplastic epithelium and the presence of intense chronic *P < 0.05, W2 test.
inflammation (hematoxyln-eosin stain, original magnification 200).

e284 * 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery & Volume 25, Number 3, May 2014 Brief Clinical Studies

estingly, 6 studies, including the sample presented, were performed

TABLE 2. Distribution of the Groups According to Radiographic Measurement
(in mm) and Macroscopic Measurement (cm) for Tissue in countries with a low Human Development Index.14
Low social development is associated with a high prevalence of
Radiographic Measurement, mm Macroscopic Measurement, cm some groups of oral lesions, especially in young patients.15 This
factor may be responsible for the high prevalence of lesions asso-
Groups G2 2Y3 93 NI P* G2 2Y3 93 NI P* ciated with 3Ms in developing countries.14 Reports of lower fre-
quencies3,9 may be due to the inclusion of patients without clinical
G1 25 12 11 35 0.8745 55 18 1 9 0.8140
evidence of associated pathology9 or of patients with an indication
G2 10 3 3 14 22 6 V 2
for the prophylactic surgical removal of 3Ms in the studied samples,3
Total 35 15 14 49 0.0525 77 24 1 11 <0.0001
or because of the reduced frequency of patients seeking dental care
*P < 0.05, W test.
2
for surgical procedures associated with asymptomatic 3Ms.16
NI indicates not informed. In the present institutional study, alterations of a cystic nature
were found in approximately 70.7% (80 tissues) of the surgical
tissues sent for histopathologic analysis. It is worth noting that of the
a final sample of 764 patients was obtained, with 286 males and 113 specimens, 76 (76.7%) were partially erupted and nonerupted
478 females (Table 3). The predominant age range was between with associated lesions, by means of radiographic evaluation. These
20 and 25 years of age. There was no difference by sex distribu- data revealed a high number of lesions associated with 3Ms, in
tion (Table 4). The most predominant histological types identified agreement with the findings found in the literature.2,3,8,10,11,13,16,17
were normal follicular tissue (n = 2822) and cystic lesions (n = 491) In our sample, paradental cysts increased the number of pa-
(P < 0.05). With respect to the most prevalent type of lesions among thologies associated with 3Ms. This type of cyst has a low preva-
the 11 articles, dentigerous cysts were the most frequent type observed lence7,18; however, its etiology involves periodontal disease,18 which
(P < 0.05; Table 5), whereas paradental cysts represented only 0.05% is directly related to low socioeconomic status.19 Consequently, it is
(n = 2) of the cases. important to include paradental cysts in clinical and clinicopatho-
logic studies of lesions associated with 3Ms to identify the distri-
DISCUSSION bution of their prevalence. And with respect to sex, a discrete
predilection for women was noted, but sex was not a determinant
Discussions of the prophylactic removal of 3Ms have continued to factor for the occurrence of pathological alterations in the dental
be controversial, mainly because of the lack of a consensus follicles.
concerning the circumstances in which this surgical procedure The mean age of patients examined in this study was 24 years,
should be performed.3,8 Normally, the oral-maxillofacial surgeon which is in agreement with the findings of the literature review, in
opts for the removal of these teeth; however, there is still a scarcity of which the age varied from 21.10 to 32.70 years. The most affected
scientific basis for this removal. 2,3,6,7,9Y11 The indications for re- age range observed in the systematic review of the literature was
moval include carious lesions, pathological reasons, orthodontic from 20 to 25 years in 5 articles,6,10,11,13,17 considering that 2 arti-
indications, and periodontal disease, among others.3,6,7,9,11 Brkic cles1,11 were excluded because of absence of age-related information.
et al9 related that among 50 teeth that were histologically evaluated, In the current study, it was observed that 56.6% (n = 64) of the cases fit
only 3 (6%) presented pathological alterations, 2 of a cystic nature into the previously mentioned age range. In the group involving 3Ms
and 1 tumor. These data corroborate some of the studies in the associated with pathological alterations, approximately 60% of the
literature review, which showed an incidence of lesions ranging from cases fit into the age range from 20 to 25 years, which was statistically
2% to 6.2%.12 In the systematic review performed in the current significant.
study, among the 11 articles, the prevalence of pathological alter- Stathopoulos et al6 observed a high frequency of cysts associated
ations of any order was 40% or greater in 7 articles.1,10Y13 Inter- with 3Ms in a sample of patients with a mean age of 32.90 years, the

TABLE 3. Number of Patients, Surgical Specimens, and Lesions Obtained From the Systematic Literature Review

Author (Year) No. Patients No. Surgical Specimens Ratio P* No. Lesions (%)
17
Glosser and Campbell (1999) 63 96 1.52/1.00 0.1094 31 (32.2%)†
Rakprasitkul13 (2001) 92 104 1.13/1.00 0.8409 61 (58.6%)†
Baykul et al10 (2005) 94 94 1.00/1.00 0.6771 47 (50.0%)†
Al-Khateeb and Bataineb7 (2006) 1398 2432 1.74/1.00 0.0007 270 (11.1%)†
Mesgarzadeh et al11 (2008) 170 171 1.00/1.00 0.6571 92 (53.8%)†
Yildirim et al3 (2008) 115 120 1.04/1.00 0.8300 28 (23.3%)†
Saravana et al8 (2008) 100 100 1.00/1.00 0.6721 46 (46.0%)†
Brkic et al9 (2010) 50 50 1.00/1.00 0.7314 3 (6.0%)†
Kotrashetti et al2 (2010) 30 41 1.37/1.00 0.4055 24 (58.5%)†
Stathopoulos et al6 (2011) 6182 417 0.07/1.00 <0.0001 215 (51.5%)†
Simzek-Kaya et al27 (2011) 50 50 1.00/1.00 0.7314 36 (72.0%)
Current study 120 113 1.09/1.00 83 (73.0%)
Total 8464 3788 0.45/1.00 <0.0001 936 (24.7%)‡

*W2 Test.
†P < 0.05 (difference in proportions test).
‡P < 0.05 (W2 test).

* 2014 Mutaz B. Habal, MD e285

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Brief Clinical Studies The Journal of Craniofacial Surgery & Volume 25, Number 3, May 2014

TABLE 4. Patients Data (Sex and Mean Age) Obtained From the Systematic Literature Review

Author (Year) Male, n (%) Female, n (%) Ratio P* Mean Age, y

17
Glosser and Campbell (1999) 26 (42) 36 (58) 0.72/1.00 0.5360 22
Rakprasitkul13 (2001) 37 (40.2) 55 (60) 0.67/1.00 0.6555 26
Baykul et al10 (2005) 30 (32) 64 (68) 0.47/1.00 0.4295 21.1
Al-Khateeb and Bataineb7 (2006) NI NI NI NI NI
Mesgarzadeh et al11 (2008) 48 (28) 123 (72) 0.39/1.00 0.1068 NI
Yildirim et al3 (2008) 38 (33) 77 (67) 0.49/1.00 0.5141 24.7
Saravana et al8 (2008) 50 (50) 50 (50) 1.00/1.00 0.0592 28
Brkic et al9 (2010) 25 (50) 25 (50) 1.00/1.00 0.0930 NI
Kotrashetti et al2 (2010) 10 (33.3) 20 (66.6) 0.50/1.00 0.6979 NI
Stathopoulos et al6 (2011) NI NI NI NI 32.7
Simzek-Kaya et al27 (2011) 22 (44) 28 (56) 0.79/1.00 0.4101 NI
Current study 42 (37.1) 71 (62.8) 0.59/1.00 24
Total 338 (38.1) 549 (61.8) 0.61/1.00 0.8466 25.5
2
*W Test.
NI indicates not informed.

highest mean age observed in the literature review presented. This
finding is inconsistent with the high Human Development Index of
the country where the study was conducted (Greece).14 These data
may be explained by a possible direct association between age and
frequency of cysts in mandibular 3Ms. However, in our sample, this
ratio was low.20
Further studies are needed to define this association because if
this relationship in fact exists, the prophylactic surgical removal of
3Ms becomes advisable.9,12 Delaying surgery until after the estab-
lishment of pathology only diminishes the patient’s quality of life
because in minor oral surgery, age is directly proportional to post-
operative complications (pain, swelling, osteitis, and difficulty of
healing).21Y23
With respect to the histological findings, a greater number of
cases were concentrated in the group with reference to cystic alter-
ations, followed by the group with reference to normal pericoronal
follicles, which differed from the findings in the literature review. In
the review, the largest number of patients was in the group whose
histological diagnosis was consistent with unaltered pericoronal
follicles, which represented approximately 78.1% of the cases,
followed by the group with cystic alterations, which represented
approximately 11% of cases. This fact may be related to the rela-
tively reduced size of the sample in the current study, which nev-
ertheless does not invalidate the data. Dentigerous cysts represented
the most prevalent lesion cited in the literature, with approximately
11% of a total of 3531 dental follicles evaluated, whereas only 2
cases were consistent with the diagnosis of paradental cysts. In the
current study, the paradental cyst (P < 0.0001) was the most prev-
alent, followed by the dentigerous cyst, which differs widely from
the literature. It is believed that this difference in the prevalence of
the 2 cystic lesions may be explained by the fact that the majority of
articles had a high number of nonerupted teeth, which could elim-
inate the possibility of a larger number of cases of paradental cysts.
Another important consideration is the World Health Organization
classification with regard to paradental cysts, which could induce
differences in the outcomes of the histopathologic diagnosis.24
Therefore, the high prevalence of paradental cysts confirms the need
for the removal of partially erupted 3Ms, particularly in the age
range from 20 to 25 years, including those with the absence of
clinical symptoms.
Regarding the radiographic size of the pericoronal space, there is
no consensus about the value at which it is suggestive of patho-
logical alterations.2,3,6Y13,17 The majority of the 11 articles selected
only teeth with a radiographic follicular size that was smaller than

TABLE 5. Distribution of the Most Prevalent Lesions According to the Systematic Review of the Literature

Author (Year) Dentigerous cyst, n (%) Normal Follicle, n (%) Rate P* Paradental cyst, n (%)
17
Glosser and Campbell (1999) 31 (32)† 65 (68)† 0.48/1.00 0.0793 0†
Rakprasitkul13 (2001) 53 (51)† 43 (41)† 1.23/1.00 0.4104 0†
Baykul et al10 (2005) NI NI NI NI NI
Al-Khateeb and Bataineb7 (2006) 19 (1)† 2162 (89)† 0.01/1.00* <0.0001 2 (0.1)†
Mesgarzadeh et al11 (2008) 65 (38)† 79 (46)† 0.82/1.00 0.7629 0†
Yildirim et al3 (2008) 17 (14) 92 (77)† 0.18/1.00* <0.0001 0†
Saravana et al8 (2008) 46 (46)† 54 (54)† 0.85/1.00 0.8482 0†
Brkic et al9 (2010) 2 (4)† 47 (94)† 0.04/1.00* <0.0001 0†
Kotrashetti et al2 (2010) 18 (44)† 17 (41)† 1.06/1.00 0.7438 0†
Stathopoulos et al6 (2011) 138 (33)† 202 (48)† 0.68/1.00 0.3657 0†
Simzek-Kaya et al27 (2011) NI NI NI V NI
Current study 21 (17) 23 (22) 0.91/1.00 1.0000 55 (54)
Total 410 (11)† 2784 (76)† 0.14/1.00† <0.0001 57 (1.5)†

*W2 Test.
†P < 0.05 (difference in proportions test).
NI indicates not informed.

e286 * 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery & Volume 25, Number 3, May 2014
2.50 mm. Mesgarzadeh et al11 radiographically evaluated the pericoronal
space of 185 mandibular 3Ms apparently without alterations from nor-
mality (follicular space <3 mm) and found associated pathologies in 50%
of the cases. In the current study, no restriction was applied regarding the
radiographic size of the follicular space; however, 50 surgical tissues
(44.2%) measuring between 0 and 3 mm were found. Among these, 37
specimens presented alterations of a cystic nature. It is believed that the
radiographic evaluation of the pericoronal follicle space may not be a
predictor of pathological alterations, and there may be an elevated
number of false-positive results. On the other hand, the macroscopic size
evaluated in the current study, which was not found in the literature,
revealed a statistically significant prevalence in the group of follicles with
pathological alterations for surgical tissues less than 2 mm. It is therefore
believed that surgical tissues smaller than 2 mm may be associated with
pathological alterations, even though the pericoronal radiolucent space
does not radiographically attain significant proportions.
Because the size of the specimen is an important factor for dif-
ferentiation between a dilated dental follicle and a dentigerous
cyst,25 any distortion generated in the panoramic radiograph can
interfere with diagnosis.16 This factor increases the value of the
macroscopic dimensions of the specimen, as supported by the dif-
ferential diagnosis for laboratory analysis. It is important, however,
to emphasize that fixation with 10% formaldehyde for an adequate
length of time causes significant tissue contraction,26 which de-
creases the cutoff point between the radiographic differentiation of a
dentigerous cyst and an enlarged dental follicle, which is usually
suggested in the literature.25
In conclusion, the data obtained in both the present prospective
study and the systematic review confirm that mandibular 3Ms whose
pericoronal follicles present a radiographic aspect of normality may
be associated with pathological lesions. The mandibular 3Ms in
young adults showed a direct relationship with age and a statistical
propensity for the development of these cystic alterations, notably
paradental cysts.
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Brief Clinical Studies
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Freeman-Sheldon Syndrome and
Respiratory Obstruction: A Novel
Use of Distraction Osteogenesis
Jason D. Toranto, MD,* Sally Davidson Ward, MD,Þ
Aaron Lin, MD,þ Mark M. Urata, MD, DDS§
Abstract: Freeman-Sheldon syndrome, or distal arthrogryposis type
IIA (DA 2A), is a rare and severe multiple congenital contracture
syndrome that is associated with upper airway obstruction. This
obstruction has been clinically significant enough to warrant tra-
cheostomy and has been associated with mortality. We describe a
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