Multiple calcifying hyperplastic dental follicles: A case report
A 31-year-old female visited our clinic with the complaints of pain and gingival swelling on the left maxillary alveolar region and consequent difficulty of eating. Her dental history revealed that she had a dental visit due to her carious and crowded teeth when she was 17 years old. Her carious molar teeth had been extracted and she had applied for orthodontic treatment. The palatally positioned left maxillary incisor teeth were treated for a four-year period. At that time, her impacted teeth were diagnosed on routine radiographs, and she had a surgical operation for the extraction of one of her impacted right mandibular teeth at the age of 18. Her orthodontist followed up on the eruption of the other impacted teeth yearly until she was 21 years old, but then she interrupted her dental treatment and follow-up visits until our examination.\nThe patient had also been diagnosed with hypothyroidism when she was five years old. She was undergoing levothyroxine sodium (Levotiron®, Abdi İbrahim, Istanbul, Turkey) therapy, and her T3, T4, and TSH hormone levels were normal. On extraoral examination, she was approximately 1.50 meters tall and had sparse hair. Intraoral examination revealed missing teeth, diastemata, macroglossia, and buccolingual expansion of the alveolar bone ().\nA panoramic radiograph revealed six impacted permanent teeth: the third molar teeth in all quadrants and the maxillary canine teeth. The crowns of these impacted teeth were surrounded with cyst-like lesions containing radiopaque foci, and well-defined corticated borders. The impacted mandibular molar teeth were located in the apical direction near the inferior cortex of the mandible, and the impacted maxillary teeth were located close to the floor of the maxillary sinus (). For further information, computed tomography was performed. Axial sections of the mandible revealed rounded radiolucent lesions associated with the crowns of the right and left mandibular molar teeth. These lesions contained radiopaque foci and were interpreted as calcification (). In axial sections of the maxilla, the mixed appearance of the lesions with well-defined borders was noteworthy ().\nAfter surgically exposing the impacted left mandibular third molar tooth, an incisional biopsy specimen was obtained from the center of the lesion, under direct vision. Subsequent to biopsy, histopathological examination of the specimen obtained from the follicle of the tooth was made. Microscopic examination revealed loose to moderately dense collagenous connective tissue with abundant calcified material and sparse epithelial islands. The calcifications were mostly acellular type 1 calcification but scanty cellular type II calcifications were also detected. Inflammatory cell infiltration was not observed (). A diagnosis of dental follicles with calcifications was made.\nThe patient refused a surgical operation for removal of the impacted teeth, and she was scheduled for a follow-up visit. One year later, there was not any alteration in the radiographic appearance of the lesions, and then the patient was lost to follow-up. Five years later, the patient showed up for a follow-up appointment. A new panoramic radiograph revealed slight enlargement of the calcified follicles and an increase in the density of the calcifications. A focal increase in the radiopacity associated with the crown of the right mandibular third molar tooth, a small radiopaque prominence associated with the inferomedial aspect of the follicle of the left mandibular third molar tooth, and irregularity of the contours of the hyperplastic follicles were detectable on the radiograph made five years after initial presentation (). The patient refused any surgical operation or prosthetic restoration again.