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CASE REPORT
Year : 2015  |  Volume : 33  |  Issue : 1  |  Page : 53-56
 

Conservative management of large radicular cysts associated with non-vital primary teeth: A case series and literature review


1 Department of Pediatric Dentistry, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India
2 Department of Oral and Maxillofacial Surgery, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India

Date of Web Publication9-Jan-2015

Correspondence Address:
Dr. K S Uloopi
Department of Pediatric Dentistry, Vishnu Dental College, Vishnupur, Bhimavaram - 534 202, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.149007

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   Abstract 

Radicular cysts are the most common odontogenic cystic lesions of inflammatory origin. Large radicular cyst is comparatively less frequently associated with primary teeth. They represent only 0.5-3.3% of the total number of cysts in primary dentition. Radicular cysts arising from deciduous teeth are reported to occur in age range of 3-19 years with a male predominance. Although large radicular cysts are treated by enucleation with extensive removal of bone and vital teeth, marsupialization can be preferred as a conservative approach to reduce the morbidity. The purpose of this article is to report a case series of large radicular cysts associated with badly mutilated and traumatized primary teeth and to demonstrate how best they can be conservatively treated during mixed dentition period.


Keywords: Marsupialization, nucleation, obturator, primary teeth, radicular cyst


How to cite this article:
Uloopi K S, Shivaji RU, Vinay C, Pavitra, Shrutha S P, Chandrasekhar R. Conservative management of large radicular cysts associated with non-vital primary teeth: A case series and literature review. J Indian Soc Pedod Prev Dent 2015;33:53-6

How to cite this URL:
Uloopi K S, Shivaji RU, Vinay C, Pavitra, Shrutha S P, Chandrasekhar R. Conservative management of large radicular cysts associated with non-vital primary teeth: A case series and literature review. J Indian Soc Pedod Prev Dent [serial online] 2015 [cited 2019 May 25];33:53-6. Available from: http://www.jisppd.com/text.asp?2015/33/1/53/149007



   Introduction Top


Children exhibit many pathological lesions involving the jaw bones. Among them, odontogenic cysts constitutes an important aspect of oral and maxillofacial pathology as they are derived from epithelium associated with the development of the dental apparatus. The most common among these lesions of inflammatory origin are radicular cysts, which are common sequelae of dental caries. [1]

Radicular cyst is an odontogenic cyst, which is derived from the inflammatory activation of epithelial root sheath residues of cell rests of Malassez in the periodontal ligament. [2] Radicular cysts are less frequently associated with primary dentition, representing only 0.5-3.3% of the total number of cysts in primary dentition. [3] It has been reported that development of a radicular cyst in primary teeth accounted for less than 1% of all cases [3] , whereas another study found that total 51 cases of radicular cysts associated with primary teeth are reported, including their 23 cases from 1898 to 1983. [4] It has been stated that 112 cases of radicular cysts with primary teeth have been reported in the dental literature from 1927 to 2004. [5] Although large radicular cysts are treated by enucleation with extensive removal of bone and vital teeth, marsupialization can be preferred as a conservative approach to reduce the morbidity. The purpose of this article is to report a series of cases of large radicular cysts and discuss the clinical features and conservative management of the lesion in children.


   Case Report Top


Case 1

An 11-year-old male patient reported to the Department of Pediatric Dentistry with the chief complaint of pain and swelling in the upper left front teeth region since 20 days. The patient gave a previous history of trauma to the same region for which no treatment was taken. On extra-oral examination, a diffuse, non-tender, firm swelling measuring 2 × 2 cm in size was noted on the left cheek. Intraoral examination revealed firm bony hard swelling with buccal and lingual cortical expansion in the region of retained 61-63. OPG revealed a well-defined periapical radiolucency involving tooth buds of 21, 22, and displaced 23. Fine needle aspiration cytology (FNAC) revealed straw-colored fluid. Therefore, based on patient's clinical findings, radiographic investigations, and FNAC report, the provisional diagnosis of radicular cyst was made. Marsupialization was performed by creating a window in the buccal cortical plate, and a drain was positioned followed by extraction of 61, 62, and 63. Histopathological investigation showed the presence of stratified squamous epithelium with vacuolations and inflammatory cellular infiltration suggesting of radicular cyst. Regular irrigation with Betadine and saline was carried out for a period of 2 weeks. Eruption of 21 and 22 was noted with a favorable positional change of 23 after 1 year follow-up period, and the patient is undergoing fixed orthodontic treatment for the further alignment of teeth [[Figure 1]a-d].
Figure 1: (a) Pre-operative intraoral view showing expansion of both cortical plates; (b) Pre-operative orthopantamograph showing periapical radiolucency involving maxillary left incisor regions; (c) Post-operative intraoral view showing favorable eruption of 21 and 22; (d) Panaromic radiograph showing bone regeneration after 1 year postoperatively

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Case 2

A 10-year-old girl reported with the complaint of pain and swelling in the lower left back teeth region since 1 week. On extraoral examination, a diffuse, non-tender, bony hard swelling was noticed on the left side of the body of the mandible measuring 2 × 3 cm in size. Intraoral examination revealed grossly decayed 75 with buccal cortical plate expansion. A well-defined periapical radiolucency measuring about 1.5 × 2cm in size involving tooth bud of 35 was noticed in OPG. Clinical, radiographic examination, and FNAC reports were suggestive of radicular cyst associated with 75. Marsupialization was planned by creating a window in the buccal cortical plate followed by extraction of 75 under local anesthesia. This is followed by the placement of an acrylic obturator to maintain a patent surgical opening and prevent food accumulation. Iodoform pack was given to reduce the postoperative pain and infection. The histopathological examination confirmed our provisional diagnosis of a radicular cyst. It showed the presence of stratified squamous epithelium with subadjacent granular tissue and inflammatory infiltration. Fixed space maintainer was given later to guide the eruption of premolars. At 2 years recall, 35 was erupted in its normal position and new bone formation was found around the erupted tooth [[Figure 2]a-d].
Figure 2: (a) Pre-operative intraoral view showing grossly decayed 75 with buccal cortical plate expansion; (b) Pre-operative occlusal radiograph showing buccal cortical plate expansion; (c) Post-operative intraoral view showing favorable eruption of 35; (d) IOPAR after 2 years postoperatively showing new bone formation around 35

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Case 3

An 11-year-old boy reported with a brief complaint of pain and swelling in the upper left front teeth region since 1week. The patient gave a previous history of trauma to the same region for which no treatment was taken. On extraoral examination, a diffuse, non-tender, firm swelling measuring 1.5 × 1.5 cm in size was noticed on the left side of cheek. Intraoral examination revealed firm bony hard swelling with buccal and lingual cortical expansion in relation to retained 61. Orthopantomograph (OPG) revealed a well-defined periapical radiolucency measuring about 2 × 2 cm in size involving horizontally displaced 21, 22, and 23. The differential diagnosis being traumatic bone cyst, globulomaxillary cyst, and aneurysmal bone cyst. Based on clinical, radiographic examination, and FNAC report a provisional diagnosis of radicular cyst associated with retained 61 was made. Marsupialization was planned by creating a window in the buccal cortical plate followed by extraction of 61, and brackets were positioned on surgically exposed 21 and 23. Histopathological examination showed the presence of odontogenic cystic epithelium with vacuolations and inflammatory infiltration. After regular follow-up of 1 year, favorable eruption of teeth was noticed and patient is on fixed orthodontic therapy [[Figure 3]a-d].
Figure 3: (a) Pre-operative intraoral view showing swelling in relation to discolored 61; (b) Extra-oral radiograph showing periapical radiolucency involving horizontally displaced 21, 22, and 23; (c) 1-year post-operative photograph showing forced eruption of 21; (d) Post-operative occlusal radiograph showing healed lesion

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Case 4

An 8-year-old male patient visited our Department with the chief complaint of pain and swelling in the upper right front teeth region since 1 month. There was a previous history of trauma to the same region. It was his first dental visit. On extra-oral examination, a diffuse, non-tender, firm swelling measuring 2 × 3 cm in size was noticed on the right cheek. Intraoral examination revealed firm bony hard swelling extending from the region of 51-54 with 51, 52, and 61 being non-vital. OPG revealed well-defined radiolucency measuring about 1.5 × 2 cm in size involving tooth buds of 11, 12, and 13. A light-yellow blood-mixed fluid was collected on aspiration. Based on clinical findings and laboratory investigations, the provisional diagnosis of radicular cyst was made. Conservative treatment of marsupialization was planned by creating window in the buccal cortical plate, and a drain was positioned followed by extraction of 51, 52, and 61. Histopathological examination showed the presence of arcading pattern of hyperplastic odontogenic cystic epithelium with subadjacent granular tissue and collagen bundles with inflammatory cellular infiltration suggesting of radicular cyst. Regular irrigation with Betadine and saline was carried out for a period of 1 week. At 8 months recall visit, eruption of 11 and 12 was noticed with healing of lesion [[Figure 4]a-d].
Figure 4: (a) Pre-operative intraoral view showing swelling in relation to traumatized 51 and 52; (b) Pre-operative OPG showing radiolucency involving tooth buds of 11, 12, and 13; (c) Postoperative intraoral view showing eruption of 11 and 12; (d) OPG after 8 months postoperatively showing the healing of lesion

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   Discussion Top


Radicular cyst, also known as periapical cyst, is usually associated with carious, non-vital, discolored or fractured tooth. [6] Radicular cysts comprise about 52-68% of all the cysts affecting the human jaw. [7] Radicular cysts arising from deciduous teeth are reported to occur in age range of 3-19 years with a male predominance. The most commonly involved deciduous teeth are mandibular molars (67%), maxillary molars (17%) followed by anterior teeth. [8] Our cases were in 8-11 years age group with male predominance. In our cases, radicular cysts were associated with primary carious mandibular molar and traumatized maxillary anterior teeth.

The reason for the low incidence of radicular cyst in primary teeth compared with permanent teeth is thought to be the shorter life span of primary teeth in the jaw, easy drainage in deciduous teeth due to presence of numerous accessory canals, and radiolucencies in relation to deciduous teeth are usually neglected. Additionally, the lesions tend to resolve on their own following the extraction or exfoliation of the associated tooth and are generally not submitted for histopathological examination. [2],[9] The most common clinical and radiographic features associated with radicular cyst in children are buccal cortical plate expansion, well-defined unilocular radiolucency, thin reactive cortex, and displacement of succedaneous teeth. [2]

Other odontogenic lesions tend to mimic radicular cyst are periapical granuloma and dentigerous cyst. In differentiation from a dentigerous cyst, it is important to confirm whether the position of the permanent tooth germ is retained or displaced. Because it has been reported that a radicular cyst can include the crown of consecutive permanent teeth, a definitive diagnosis of the disease requires a comprehensive assessment based on clinical, radiographic, and histopathological findings. [4],[10]

A histopathologic feature of radicular cyst is characterized by the presence of stratified squamous epithelial lining, which may demonstrate exocytosis, spongiosis, or hyperplasia. The lumen is filled with fluid and cellular debris. The wall of the cyst consists of dense fibrous connective tissue, often with an inflammatory infiltrate containing lymphocytes variably intermixed with neutrophils, plasma cells, histiocytes, and rarely mast cells and eosinophils. [1] The above-mentioned histopathological features were similar to the findings noted in our cases. Histological examination showed the presence of amorphous eosinophilic material in the radicular cyst wall of primary teeth. [11] It was suggested that antigen stimulation by various products used for endodontic treatment of primary teeth may be related to the development and rapid growth of a radicular cyst in primary teeth. It has been reported that the number of immunocompetent cells in the dental pulp of primary teeth is significantly higher than in permanent teeth. [12] However, there is no difference in the inflammatory reaction in carious tooth between primary and permanent teeth. Thus, it seems that there is no specific relationship of cyst development and the activity of dental pulp.

Several treatment options are available for a radicular cyst such as endodontic treatment, extraction of the offending tooth, enucleation with primary closure, and marsupialization. The surgical approach to cystic lesions of the jaws is either marsupialization or enucleation. The treatment of choice is dependent on the size and localization of the lesion, the bone integrity of the cystic wall, and its proximity to vital structures. [13] Large cysts can pose a problem in mixed dentition stage because the cystic pressure may lead to the deviation of the developing tooth buds, and in some cases, impaction of permanent teeth may also occur. [14],[15] In mixed dentition stage, if the cyst is small, the treatment of choice is enucleation; however, if the cyst is large and in close proximity to important structures then marsupialization is the recommended treatment modality. Cysts are usually enucleated, where the cystic lining is separated from its inner bony surface and removed and the cavity is allowed to fill with blood clot. Alternatively, the cyst may be marsupialized to relieve the internal pressure. [15],[16]

The principle behind marsupialization is to make an opening or fenestration on the outer wall of the cyst through which the cystic content drains into the oral cavity leading to bony in growth in the cavity. Gradually, cyst is reduced in size to an extent that cystic lining becomes continuous with the oral epithelium and is changed by metaplasia into oral mucous membrane. [17] Marsupialization is successful because, once the liquid contents are released, cystic lining has an inherent tendency to contract due to the presence of myofibroblasts in their walls, followed by formation of endosteal bone. [18] The main drawback of marsupialization in children is that this procedure needs patient compliance to irrigate the cavity regularly to keep it clean. Furthermore the large cavity left uncovered might alter the voice. Regular follow-up visits are necessary to see that the cavity is filling up in a uniform fashion and to adjust the size of the acrylic plug. [19],[20],[21]

Marsupialization is favored because of lower morbidity, preservation of permanent tooth buds and the bony in growth occurs as the lesion shrinks in size, resulting in more normal bone contour. In children, healing of the post-surgical osseous defects is always good as they have high propensity for bone regeneration. In all our cases, complete healing was observed with conservation of vital structures using minimal invasive approach. Despite the limitations of marsupialization technique, it has got advantages of preserving the bone and vital teeth. Therefore, it is worthwhile to consider the conservative approach in managing large radicular cysts during mixed dentition period.

 
   References Top

1.
Neville B, Damm D, Allen C, Bouquot J. Oral and Maxillofacial Pathology. 3 rd ed. Elsevier; 2008.  Back to cited text no. 1
    
2.
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. 2
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3.
Shear M. Cyst of the Oral Region. 2 nd ed. Butterworth-Heinemann Ltd; John Wright and Sons; 1983.  Back to cited text no. 3
    
4.
Lustmann J, Shear M. Radicular cysts arising from deciduous teeth. Review of the literature and report of 23 cases. Int J Oral Surg 1985;14:153-61.  Back to cited text no. 4
    
5.
Nagata T, Nomura J, Matsumura Y, Yanase S, Fuji T, Oka T, et al. Radicular cyst in deciduous tooth: A case report and review of literature. J Dent Child (Chic) 2008;75:80-4.  Back to cited text no. 5
    
6.
Joshi NS, Sujan SG, Rachappa MM. An unusual case report of bilateral mandibular radicular cysts. Contemp Clin Dent 2011;2:59-62.  Back to cited text no. 6
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7.
Nair PN. New perspectives on radicular cysts: Do they heal? Int Endod J 1998;31:155-60.  Back to cited text no. 7
    
8.
Elango I, Baweja DK, Noorani H, Shivaprakash PK. Radicular cysts associated with deciduous molar following pulp therapy: A case report. Dent Res J 2008;5:95-8.  Back to cited text no. 8
    
9.
Shetty S, Angadi PV, Rekha K. Radicular cyst in deciduous maxillary molars: A rarity. Head Neck Pathol 2010;4:27-30.  Back to cited text no. 9
    
10.
Mass E, Kalpana I, Hishberg 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. 10
    
11.
Savage NW, Adkins KF, Weir AV, Grundy GE. A histological study of cystic lesions following pulp therapy in deciduous molars. J Oral Pathol 1986;15:209-12.  Back to cited text no. 11
    
12.
Rodd HD, Boissonade FM. Immunocytochemical investigation of immune cells within human primary and permanent tooth pulp. Int J Paediatr Dent 2006;16:2-9.  Back to cited text no. 12
    
13.
Shafer HL. Textbook of Oral Pathology. 6 th ed. Amsterdam: Elsevier; 2006.  Back to cited text no. 13
    
14.
Sokler K, Sandev S, Grgurevi J. Surgical treatment of large mandibular cysts. Acta Stomatol Croat 2001;35:253-7.  Back to cited text no. 14
    
15.
Bodner L. Cystic lesions of the jaws in children. Int J Pediat Otorhinolaryngol 2002;62:25-9.  Back to cited text no. 15
    
16.
Riachi F, Tabarani C. Effective management of large radicular cysts using surgical enucleation vs. marsupialization two cases report. Int Arab J Dent 2010;1:45-51.  Back to cited text no. 16
    
17.
Nawaz MS, Yazdanie N, Faheemuddin M. Rehabilitation of a cystic mixed dentition mandible following marsupialization with a multipurpose acrylic splint acting as a space maintainer and an obturator. J Ayub Med Coll Abbottabad 2011;23:177-9.  Back to cited text no. 17
    
18.
Marchetti C, Bonetti GA, Pieri F, Checchi L. Orthodontic extraction: Conservative treatment of impacted mandibular third molar, associated with a dentigerous cyst. A case report. Quintessence Int 2004;35:371-4.  Back to cited text no. 18
    
19.
Howe GL. Minor Oral Surgery. 3 rd ed. London: Butterworth & Co.; 1985.  Back to cited text no. 19
    
20.
Varinauskas V, Gervickas A, Kavoliuniene O. Analysis of odontogenic cysts of the jaws. Medicina (Kaunas) 2006;42:201-7.  Back to cited text no. 20
    
21.
Kirtaniya BC, Sachder V, Singla A, Sharma AK. Marsupialization: A conservative approach for treating dentigerous cyst in children in the mixed dentition. J Indian Soc Pedod Prev Dent 2010;28:203-8.  Back to cited text no. 21
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