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Radicular cyst


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case presentation of a 55 y/o male with a left mandibular radicular cyst.

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Radicular cyst

  1. 1.   Data, De Castro, Ghobadyfard, Rohani, Azinfar, Seyed Arab Grp. 3
  2. 2.  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.
  3. 3.  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.
  4. 4.  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.
  5. 5. General Data:  A.F.  55 y/o  Male  Married  Filipino  Roman Catholic  Antipolo
  6. 6.  Left mandibular mass
  7. 7. 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
  8. 8. 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
  9. 9. (-) Hypertension (-) Diabetes Mellitus (-) Allergies to food or medication
  10. 10. (-) Hypertension (-) Diabetes Mellitus (-) Cancer
  11. 11.  41 pack years  Drinks occasionally consuming 3-4/week  Denies illicit drug used
  12. 12. 
  13. 13.  No cervical lymphadenopathies  No mass palpated
  14. 14.  No gross deformity  No tragal tenderness  Intact TM, pearl white appearance, non-bulging  No ear discharge  Non hyperemic canal
  15. 15.  No gross deformity/deviation  No nasal discharge  No epistaxis  (-) congestion  No polyps  No masses
  16. 16.  Presence of mass  Presence of swelling
  17. 17.  Vocal cord equally moving  No mass noted  No edema  Non-hyperemic
  18. 18.  No mass noted
  19. 19. 
  20. 20. 
  21. 21.  Cyst is a pathological fluid-filled cavity lined by epithelium. o Components of a cyst: Lumen (cavity), Epithelial lining, Wall (capsule)
  22. 22.  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.
  23. 23.  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.
  24. 24.  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.
  25. 25.  Most common location: (maxilla 3x more affected) o Maxillary anterior region o Maxillary posterior region o Mandibular posterior region o Mandibular anterior region
  26. 26.  Usually asymptomatic  Slowly progressing o If infection enters, the swelling becomes painful and rapidly expands o Initially swelling is round and hard o 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.
  27. 27.  The main factors in the pathogenesis of cyst formation are: o Proliferation of epithelial lining and fibrous capsule o Hydrostatic pressure of cystic fluid o 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
  28. 28.  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 cysts o Protein content of fluid – seen as amorphous eosinophilic material often containing broken-down leucocytes and and cells distended with fat globules
  29. 29.  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
  30. 30.  Wall/Capsule o Composed of collagenous fibrous connective tissue o Capsule is vascular and infiltrated by chronic inflammatory cells o Plasma cells are prominent or predominate o Russel bodies are often found o Pulse or Seed granulomas are often found in cyst wall
  31. 31.  Hyaline bodies (Rushton bodies): characterized by a hairpin or a slightly-curved shaped, concentric lamination and occasional basophilic mineralization. o Are within the epithelium lining o Origin believed to be previous hemorrhage o Are of no clinical significance  Russel bodies: refractile and spherical intracellular bodies representing Gamma Globulin
  32. 32.  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 borders o Background structures become invisible and the defect appears as tunneling o PDL space around the involved tooth becomes widened
  33. 33.  Treatment of a tooth with radicular cyst may include: o Tooth extraction o 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
  34. 34.  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.
  35. 35. 
  36. 36.  It can develop even after years after tooth extraction and is responsible for ameloblatomas that develop on patients older than 30 years.
  37. 37. Patient (A.F.) Radicular Cyst Dentigerous Cyst Ameloblastoma Location: 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
  38. 38. 
  39. 39.  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
  40. 40.  Department of Otorhinolaryncology, Head and Neck Surgery, Quirino Memorial Medical Center  Wikipedia (  cyst?from_search=3  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