Abstract
RATIONALE: Dentigerous cysts are the second most common odontogenic cysts and are frequently associated with impacted permanent teeth. Conventional management typically involves enucleation with extraction of the involved tooth, which often leads to tooth loss and alveolar bone resorption. This case illustrates a conservative surgical orthodontic protocol that preserved the impacted tooth, maintained alveolar bone support, and corrected the malocclusion. PATIENT CONCERNS: A 15-year-old male presented with the chief complaint of dental crowding and facial asymmetry. Clinical examination revealed mandibular deviation to the right, a canted occlusal plane, and smile asymmetry. Intraorally, he exhibited 27 permanent teeth, with retained primary molars and an unerupted mandibular left first premolar. DIAGNOSES: The patient was diagnosed with a mild skeletal Class II malocclusion due to maxillary protrusion, mandibular asymmetry, a canted occlusal plane, slight crowding in both arches, and an impacted mandibular left first premolar associated with a dentigerous cyst. INTERVENTIONS: Treatment consisted of staged decompression followed by cyst enucleation, surgical exposure of the impacted premolar, and orthodontic traction using a lingual appliance system. The impacted premolar successfully erupted into the dental arch within 5 months. OUTCOMES: Comprehensive orthodontic treatment over a 22-month period achieved proper alignment, functional occlusion, and improved smile esthetics. Despite mild root shortening of the premolar, periodontal health, bone support, and tooth stability were preserved at follow-up. LESSONS: A biologically conservative protocol combining cyst management and guided orthodontic traction can effectively manage dentigerous cyst-associated impactions while preserving the natural dentition and avoiding prosthetic replacement.