Radicular Cyst

Data, De Castro, Ghobadyfard, Rohani, Azinfar, Seyed ArabGrp. 3

Abstract Radicular cyst is the most common inflammatory

odontogenic cystic lesion. It originates from epithelial residues in periodontal ligaments, as a consequence to pulpal necrosis following caries, with an associated periapical inflammatory response.

Here, a 55-year-old male patient was presented with a complaint of painful swelling on the mandibular left 2nd premolar area.

The patient management comprised surgical enucleation of cystic sac under general anesthesia followed by rehabilitation of the same area.

Introduction Radicular cysts are the most common inflammatory cysts

arising from the epithelial residues in the periodontal ligament as a result of periapical periodontitis following necrosis of the pulp, remains asymptomatic and left unnoticed until detected during routine periapical radiography.

These cysts comprise about 52% to 68% of all the cysts affecting the human jaw. Their incidence is highest in third and fourth decade of life with male predominance. Anatomically the periapical cysts occur in all tooth-bearing sites of the jaw but are more frequent in the maxillary than the mandibular region.

Caries is the most frequent aetiological factor of radicular cyst. They also result from the traumatic injuries.

Introduction These cysts are slow growing and asymptomatic

unless secondarily infected. Extraction or endodontic treatment of the affected tooth is required when clinical and radiographic characteristics indicate a periapical inflammatory lesion.

The normal treatments for radicular cysts include total enucleation in the case of small lesions, marsupialisation for decompression of larger cysts, or a combination of the two techniques. Inflammatory cysts do not recur after adequate treatment.

Case ReportGeneral Data:

A.F. 55 y/o Male Married Filipino Roman Catholic Antipolo

Chief Complaint Left mandibular mass

History of Present Illness

2 years PTC patient underwent tooth extraction of a

carious left lower 2nd premolar. At that time no noted movable tooth beside the 2nd premolar.

4 months PTC Gradually enlarging left mandibular

mass Associated with swelling and tenderness Consulted a dentist and was given

Amoxicillin 500mg/cap TID x 1week then Co-amoxiclav 625mg/tab TID which offered relief of swelling but not of the mass

History of Present Illness

2 months PTC Patient was immediately brought to OPD

wherein panoramic xray was requested revealing unilocular radiolucency on the left side of the mandible

On follow-up was advised surgery

Past Medical History(-) Hypertension(-) Diabetes Mellitus(-) Allergies to food or medication

Family History(-) Hypertension(-) Diabetes Mellitus(-) Cancer

Personal & Social History

41 pack years Drinks occasionally consuming 3-4/week Denies illicit drug used

Physical Examination

Head & Neck No cervical

lymphadenopathies No mass palpated

Head & Neck

Head & Neck

Ears No gross deformity No tragal tenderness Intact TM, pearl white

appearance, non-bulging

No ear discharge Non hyperemic canal

Anterior Rhinoscopy No gross deformity/deviation No nasal discharge No epistaxis (-) congestion No polyps No masses

Oral Cavity Presence of mass Presence of swelling

Indirect Laryngoscopy Vocal cord equally moving No mass noted No edema Non-hyperemic

Posterior Rhinoscopy No mass noted

Panoramic X-ray

Discussion

Discussion Cyst is a pathological fluid-filled cavity lined by

epithelium.o Components of a cyst: Lumen (cavity), Epithelial lining,

Wall (capsule)

Odontogenic Cyst – a cyst in which lining of the lumen is derived from epithelium involved in tooth development.

Non-odontogenic Cyst – The epithelial lining is derived from sources other than the tooth-forming organ.

Radicular Cyst Also known as Periapical Cyst, Apical Periodontal

Cyst, Root End Cyst or Dental Cyst A cyst that most likely results when rests of

epithelial cells (Malassez) in the periodontal ligament are stimulated to proliferate and undergo cystic degeneration by inflammatory products from a non-vital tooth.

Most common odontogenic cystic lesion of inflammatory origin.

Radicular cysts are found at root apices of involved teeth. These cysts may persists even after extraction of offending tooth, such cysts are called Residual Cysts.

It is classified as follows:o 1) Periapical Cyst (70%):

These are the radicular cysts which are present at root apex.

o 2) Lateral Radicular Cyst (20%): These are the radicular cysts which are present at the opening of lateral accessory root canals of offending tooth.

o 3) Residual Cyst: These are the radicular cysts which remains even after extraction of offending tooth.

Most common location: (maxilla 3x more affected)o Maxillary anterior regiono Maxillary posterior regiono Mandibular posterior regiono Mandibular anterior region

Clinical Features Usually asymptomatic Slowly progressing

o If infection enters, the swelling becomes painful and rapidly expands

o Initially swelling is round and hardo Later part of the wall is resorbed

leaving a soft fluctuant swelling, bluish in color, beneath the mucous membrane

o When bone has been reduced to egg shell thickness a crackling sensation (crepitant) may be felt on pressure.

The main factors in the pathogenesis of cyst formation are:o Proliferation of epithelial lining and fibrous capsuleo Hydrostatic pressure of cystic fluido Resorption of surrounding bone

Infection from pulp chamber induces inflammation and and proliferation of ERM

Internal pressure is important for growth of cyst Hydrostatic pressure within cysts is about 70cm

of water (higher than capillary blood pressure of ) Net effect is that pressure is created by osmotic

tension within the cyst cavity

Histopathology Lumen:

o Cyst fluid (watery & opalescent) but sometimes viscid and yellowish

o Sometimes shimmers with cholesterol crystals (typically rectangular shaped cholesterol crystals with a notched corner is characteristic)

o Cholesterol crystals are not specific to radicular cystso Protein content of fluid – seen as amorphous eosinophilic

material often containing broken-down leucocytes and and cells distended with fat globules

Histopathology Epithelial lining:

o Non-keratinized stratified squamous epithelium

o Lacks a well-defined basal cell layer

o Thick, irregular, hyperplastic or net like forming rings & arcades

o Hyaline bodies (Rushton bodies) may be found

o Mucous cells – as a result of metaplasia

Histopathology Wall/Capsule

o Composed of collagenous fibrous connective tissueo Capsule is vascular and infiltrated by chronic

inflammatory cellso Plasma cells are prominent or predominateo Russel bodies are often foundo Pulse or Seed granulomas are often found in cyst wall

Histopathology Hyaline bodies (Rushton bodies): characterized by

a hairpin or a slightly-curved shaped, concentric lamination and occasional basophilic mineralization.o Are within the epithelium liningo Origin believed to be previous hemorrhageo Are of no clinical significance

Russel bodies: refractile and spherical intracellular bodies representing Gamma Globulin

Radiographic signs Round/ovoid radiolucency with an opaque border Apex of the tooth is within the radiolucency Adjacent teeth and structures are displaced Infected cyst:

o Poorly demarcated borderso Background structures become invisible and the defect

appears as tunnelingo PDL space around the involved tooth becomes widened

Management Treatment of a tooth with radicular cyst may

include:o Tooth extractiono Endodontic therapy – if the involved non vital tooth is to

be retained o Enucleation – all the cyst tissue will be available for

histological examination; have minimal aftercare. Potentially problematic as this may deprive adjacent teeth of their blood supply and render them non vital

o Marsupialisation – partial removal; indicated in large cysts that involves apices of adjacent teeth; requires considerable aftercare and good patient cooperation.• Disadvantage: not all cyst lining is available to histologic

examination which may lead to misdiagnosis

Surgical Enucleation The patient was subjected to enucleation of the cyst

under general anaesthesia. A (crevicular) incision was made from the (distal

surface of the mandibular first premolar until distal surface of the second molar), the mucoperiosteal flap was raised, the (mandibular second premolar and the second molar) were extracted and the cyst was removed in toto along with the root piece of the first molar. There was an intact inferior alveolar neurovascular bundle.

Flaps were repositioned and sutures were taken. The tissue specimens were sent for histopathologial examination.

Differential Diagnoses

Dentigerous Cyst

Ameloblastoma It can develop even after years after tooth

extraction and is responsible for ameloblatomas that develop on patients older than 30 years.

Patient (A.F.) Radicular Cyst Dentigerous Cyst AmeloblastomaLocation: left body of the mandible

Non-vital tooth (apex or lateral part of the tooth)

Crown of an unerupted tooth (third molars and maxillary canines )

Mandible and maxillary area

Radiologic features: unilocular radiolucency

unilocular radiolucency at the apical portion of a non-vital tooth

unilocular radiolucency, which is associated with an unerupted tooth

radiolucent, unilocular lesions, with well-demarcated, corticated borders; larger lesions : “soap bubble” or honeycomb

Microscopic features

luminal lining: nonkeratinized stratified squamous epithelium

odontogenic rests are rarely seen in the cyst wall

Cholesterol slits, foreign body giant cells, and hemosiderin deposits are common findings.

luminal lining: nonkeratinized stratified squamous epithelium

Odontogenic rests are scattered within the connective tissue

Cholesterol slits and their associated multinucleated giant cells may be present

columnar basilar cells, palisading of basilar cells, polarization of basilar layer nuclei away from the basement membrane, hyperchromatism of basal cell nuclei in the epithelial lining, and subnuclear vacuolization of the cytoplasm of the basal cells

Conclusion

Conclusion The radicular cyst is usually symptomless and detected

incidentally on plain OPG while investigating for other diseases. However, as some of them grow, they can cause mobility and displacement of teeth and once infected, lead to pain and swelling, after which the patient usually becomes aware of the problem. The swelling is slowly enlarging and initially bony hard to palpate which later becomes rubbery and fluctuant.

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.

Several treatment options are available for a radicular cyst such as surgical endodontic treatment, extraction of the offending tooth, enucleation with primary closure, and marsupialization followed by enucleation. In this case, surgical enucleation was preferred and was performed uneventfully.

To conclude, a radicular cyst is a common condition found in the oral cavity. However, it usually goes unnoticed and rarely exceeds the palpable dimension. This case illustrates a common condition that occurs in an uncommon age group and location.

References Department of Otorhinolaryncology, Head and Neck

Surgery, Quirino Memorial Medical Center Wikipedia

(http://en.wikipedia.org/wiki/Periapical_cyst#Treatment) http://www.slideshare.net/malagha/radicular-cyst?

from_search=3 http://www.slideshare.net/drabbasnaseem/radicular-cyst-

or-periapical-cyst Cawson’s Essentials of Oral Pathology & Oral Medicine –

7th edition Oral and Maxillofacial Medicine (Crispian Scully CBE) Contemporary Oral and Maxillofacial Pathology – 2nd

edition