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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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CASE REPORT
Year : 2013  |  Volume : 31  |  Issue : 3  |  Page : 191-193
 

Radicular cyst followed by incomplete pulp therapy in primary molar: A case report


Department of Pedodontics and Preventive Dentistry, Rajarajeswari Dental College and Hospital, Bangalore, Karnataka, India

Date of Web Publication11-Sep-2013

Correspondence Address:
C Nagarathna
Department of Pedodontics and Preventive Dentistry, Rajarajeswari Dental College and Hospital, Bangalore - 5600 60, Karnataka
India
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DOI: 10.4103/0970-4388.117974

PMID: 24021332

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   Abstract 

Radicular cysts are one of the most common odontogenic cyst of the jaws. However, those arising from primary teeth are rare. An 8-year-old boy reported to the Department of Pedodontics and Preventive Dentistry with the chief complaint of pain and swelling on the lower left primary molar tooth region. Radiographic examination revealed a well-defined radiolucency with continuous hyperostotic border. Considering the age of the child, size of lesion, and involvement of unerupted premolars; marsupialization was preferred as a conservative treatment of choice. The success of the treatment was evident both clinically and radiographically during the follow-up period.


Keywords: Marsupialization, radicular cyst, pulp therapy


How to cite this article:
Nagarathna C, Jaya A R, Jaiganesh I. Radicular cyst followed by incomplete pulp therapy in primary molar: A case report. J Indian Soc Pedod Prev Dent 2013;31:191-3

How to cite this URL:
Nagarathna C, Jaya A R, Jaiganesh I. Radicular cyst followed by incomplete pulp therapy in primary molar: A case report. J Indian Soc Pedod Prev Dent [serial online] 2013 [cited 2014 Oct 20];31:191-3. Available from: http://www.jisppd.com/text.asp?2013/31/3/191/117974



   Introduction Top


Radicular cyst also known as periapical cyst, apical periodontal cyst, root-end cyst, or dental cyst; originates from epithelial cell rests of Malassez in periodontal ligament as a result of inflammation due to pulp necrosis or trauma. Radicular cysts are rare in the primary dentition, with an incidence of 0.5-3.3% of the total number in both primary and permanent dentition. [1] Radicular cysts are usually asymptomatic and are left unnoticed, until detected by routine radiographic examination whereas some long standing lesions may undergo an acute exacerbation of the cystic lesion and develops signs and symptoms such as swelling, tooth mobility and displacement of an unerupted teeth. [2] It clinically exhibits as a buccal or palatal enlargement in maxilla, whereas in mandible it is usually the buccal and rarely lingual. At first, the enlargement is bony hard; but as the cyst increases in size, the bony covering becomes very thin and the swelling then exhibits springiness and becomes flucluant when the cyst has completely eroded the bone. [3]

Definitive diagnosis must be based upon the clinical, radiographic, and histological evaluation. [4] When clinical and radiographic characteristics are suggestive of a periapical inflammatory lesion, extraction or endodontic treatment of the affected tooth is advised and the management of radicular cysts include total enucleation in the case of small lesions, marsupialization for decompression of larger cysts, or a combination of the two techniques. Marsupialization is usually preferred in case of radicular cyst of primary teeth to preserve the vitality of unerupted successors, where a surgical window is created by removing a part of cystic lining to enable drainage of cystic content and loss of cystic pressure followed by which a pack is given to promote reepithelization and to provide antimicrobial property.

Radicular cyst associated with primary molar following incomplete pulp therapy and its management is presented.


   Case Report Top


An 8-year-old boy reported to Department of Pedodontics and Preventive Dentistry, Rajarajeswari Dental College and Hospital, Bangalore with the chief complaint of pain in lower left back tooth region since 1 month. The pain was insidious in onset, intermittent, dull aching type, and aggravates during the night and relieves on taking medication. Pulp therapy on mandibular left primary second molar was initiated before 1 year previously and was incomplete due to poor compliance of the child and parent towards the treatment.

The child was alert, conscious, moderately built, and nourished. On extraoral examination, a diffuse swelling was present on the lower left back tooth region, extending from corner of the mouth to angle of mandible anteroposteriorly, and from ala of nose to base of the mandible superioinferiorly with local rise in temperature. Submandibular lymph nodes showed tenderness and were palpable on the involved side. Intraoral examination revealed grossly destructed mandibular left primary second molar with open wide cavity containing cotton pellet with pulpal medicaments and mobility of mandibular left primary first molar presented with vestibular tenderness and obliteration [Figure 1]a. Mandibular left second molar was tender on percussion. The intraoral lesion was rubbery and fluctuant on palpation.
Figure 1: Clinical picture (a) Pre-operative, (b) Post-Operative

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The panoramic radiograph [Figure 2] revealed a well-defined unilocular radiolucency in left mandibular posterior region with continuous hyperostotic border extending from the mesial surface of mandibular left primary first molar to the distal surface of mandibular left permanent first molar suggestive of a cyst. The radiolucency also involved the unerupted mandibular left premolars.
Figure 2: Orthopantomograph (OPG) showing well-defined continuous hyperostotic border in relation to lower left primary molar region

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Extraction of the mandibular left primary first and second molars under local anesthesia followed by marsupialization of the cyst was carried out. Cystic content was drained out and the bony tissue obtained was sent for histopathological evaluation, which confirmed the diagnosis of radicular cyst. Surgical pack with half width ribbon gauze dipped in bismuth iodoform paraffin paste (BIPP) was placed and stabilized with suture. A part of the pack was left out of the cystic space for easy retrieval. The child was prescribed with antibiotics and analgesics and also guided to maintain good oral hygiene measures. The suture and the pack were removed after 1 week.

During the follow-up period, the child responded well for the treatment with good soft tissue and hard tissue healing [Figure 1]b and [Figure 3].
Figure 3: Intraoral periapical radiographs (IOPA): Pre-operative, after one month and after 6 months.

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   Discussion Top


Most radicular cysts found in the primary dentition are associated with mandibular molars, that are most frequently affected by dental caries. Radicular cyst is generally defined as fluid-filled cavity arising from epithelial residues (rests of Malassez) in the periodontal ligament as a consequence of inflammation, usually following the death of dental pulp. [5] The literature has suggested that the incidence of radicular cyst in primary teeth is rare when compared to permanent teeth. The reason for this is thought to be the shorter period in which primary teeth are present in the jaw, compared to that for permanent teeth. [6]

Some studies have also enlightened that the pulpal medicament reacts with the apical area which may be responsible for the development of radicular cyst. The hypothesis stated that pulpal therapeutic agents may cause antigenic necrotic materials within the root canals to provide continuing antigenic stimulation in the periapical area which causes the unusual growth, especially when the pulpal medications involve materials like formacresol and iodoform. [7],[8]

In most of the cases, periapical radiolucency relating to primary teeth tends to be misdiagnosed as a periapical granuloma of the primary teeth, or a dentigerous cyst from the permanent successors.

Although radicular cysts are radiographically indistinguishable from periapical granulomas, this type of cyst is more likely to have a thin hyperostotic border. Furthermore, the larger the lesion, the greater the occurrence of a radicular cyst. [9]

However, the diagnostic criteria includes [1],[10],[11]

Cinical

  1. Evidence of a nonvital tooth.
  2. Mandibular buccal cortical expansion.
  3. Painless lesion associated with a primary tooth.
Radiographical

  1. Well-defined unilocular radiolucency associated with a primary tooth.
  2. No involvement with a successive permanent tooth.
  3. Displacement of permanent successor.
Surgical

No association with the successive permanent tooth.

Histological

Confirmation of a cystic epithelial lining.

In the present case surgical marsupialization was considered as treatment of choice to prevent any damage to the developing permanent teeth and it is easily acceptable by the child and parents as well. The objective of marsupialization or decompression was to alleviate the intracystic pressure through an accessory cavity. Decompression procedure reduces the size of the lesion so that surgical intervention is unnecessary or if necessary will be limited to the immediate periradicular tissues of involved teeth. The procedure disrupts the integrity of lesion wall, eliminates internal osmotic pressure and promotes healing by osseous regeneration. [12],[13],[14]

However, the success of the treatment depends on the patient and parent compliance and the practice of good oral hygiene measures. The children undergoing similar treatment for radicular cyst should be followed-up postoperatively at regular intervals until the eruption of the permanent teeth to assess the success of the treatment.

 
   References Top

1.Shear M. Cysts of the Oral Regions. 2 nd ed. Bristol: John Wright and Sons; 1983.  Back to cited text no. 1
    
2.Mass E, Kaplan I, Hirshberg A. A clinical and histopathological study of radicular cysts associated with primary molars. J Oral Pathol Med 1995;24:458-61.  Back to cited text no. 2
[PUBMED]    
3.Shear M. Cysts of the oral regions. 3 rd ed. Boston: Wright; 1992. p. 136-70.  Back to cited text no. 3
    
4.Wood RE, Nortjé CJ, Padayachee A, Grotepass F. Radicular cysts of primary teeth mimicking premolar dentigerous cysts: Report of three cases. ASDC J Dent Child 1988;55:288-90.  Back to cited text no. 4
    
5.Kramer IR, Pindborg JJ, Shear M. Histological typing of odontogenic tumours. 2 nd ed. Berlin: Springer Verlag; 1992.  Back to cited text no. 5
    
6.Sprawson E. Further investigation of the pathology of dentigerous cysts with a new treatment based thereon. Proc R Soc Med 1927;20:1781-92.  Back to cited text no. 6
[PUBMED]    
7.Grundy GE, Adkins KF, Savage NW. Cysts associated with deciduous molars following pulp therapy. Aust Dent J 1984;29:249-56.  Back to cited text no. 7
[PUBMED]    
8.Hill FJ. Cystic lesions associated with deciduous teeth. Proc Br Paedod Soc 1978;8:9-12.  Back to cited text no. 8
[PUBMED]    
9.Goaz PW, White SC. Infection and inflammation of the jaws and facial bones, cysts of the jaws, benign tumors of the jaws. In: Oral Radiology Principles and Interpretation. 3 rd ed. St. Louis: Wright; 1994. p. 381-473.  Back to cited text no. 9
    
10.Takiguchi M, Fujiwara T, Sobue S, Ooshima T. Radicular cyst associated with a primary molar following pulp therapy: A case report. Int J Paediatr Dent 2001;11:452-5.  Back to cited text no. 10
[PUBMED]    
11.Ramakrishna Y, Verma D. Radicular cyst associated with a deciduous molar: A case report with unusual clinical presentation. J Indian Soc Pedod Prev Dent 2006;24:158-60.  Back to cited text no. 11
[PUBMED]  Medknow Journal  
12.Neaverth EJ, Burg HA. Decompression of large periapical cyst lesion. J Endod 1982;8:175-82.  Back to cited text no. 12
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13.Grandich RA. Healing of a massive maxillary lesion. J Endod 1977;3:119-20.  Back to cited text no. 13
[PUBMED]    
14.Samuels HS. Marsupialization: Effective management of large maxillary cysts: Report of a case. Oral Surg Oral Med Oral Pathol 1965;20:676-83.  Back to cited text no. 14
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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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