International Journal of Medical and Pharmaceutical Case Reports

Background: Simple bone cyst (SBC) is a rare intraosseous pseudocyst of the jaws that lacks an epithelial lining. It is most commonly seen in children and adolescents and is usually detected incidentally because patients are often asymptomatic.

Aims: This study aims to present an incidental case of a simple bone cyst in a paediatric patient detected during radiographic evaluation of a retained primary maxillary incisor and to emphasise the importance of a multidisciplinary diagnostic approach for accurate diagnosis and management.

Case Report: A 12-year-old female patient presented with a retained primary maxillary left central incisor and delayed eruption of the permanent successor. Panoramic radiography revealed two mesiodens associated with the unerupted permanent maxillary left central incisor. An incidental radiolucent lesion was also observed in the mandibular left premolar region between teeth 34 and 35. Further evaluation using cone-beam computed tomography showed a well-defined radiolucent cavity with mild buccolingual expansion and intact cortical plates. Surgical exploration revealed an empty bone cavity and histopathological examination showed fibrovascular connective tissue with focal haemorrhage and haemosiderin deposition, supporting the diagnosis of SBC. One-year follow-up demonstrated satisfactory bone healing without recurrence.

Conclusion: This case highlights the importance of careful radiographic assessment in paediatric patients, as clinically silent lesions may be discovered during investigation of unrelated dental concerns. A combination of clinical, radiographic, and histopathological findings is essential for establishing an accurate diagnosis and appropriate management.