Non surgical management of a radicular cyst is described along with a review of literature

2. NON SURGICAL MANAGEMENT
OF RADICULAR CYST

3. CONTENTS
 Chief complaint
 History
 Examination
 Provisional diagnosis
 Investigations
 Final diagnosis
 Treatment plan
 Discussion
 Conclusion
 References

4. CASE RECORD
NAME
OP NO
AGE
GENDER
PLACE
OCCUPATION
M. Somasekhar
2203240009
15 years
Male
Dowaleswaram
Student

5. CHIEF COMPLAINT
 Patient complains of missing upper front tooth since 1 week
HISTORY OF PRESENT ILLNESS
 Patient gave history of trauma 1 week back while playing, in the maxillary and
mandibular anterior region which resulted in avulsion of 21
 There was evidence of bleeding at the site of tooth loss which is not significant
 No loss of consciousness

6. Medical history
Past dental history
Personal history
Family history
Patient underwent surgery for unilateral cleft
lip at the age of 6 months
First visit
Patient brushes his teeth once daily with toothpaste
and toothbrush in the morning
No relevant history

7. CLINICAL EXAMINATION
 HABITS – No abnormal habits
 EXTRA ORAL EXAMINATION –
Shape of head
Facial form
Facial profile
Facial divergence
Lips
Dolicocephalic
Mesoprosopic
convex
posterior
Incompetent and everted

8. INTRA ORAL EXAMINATION
 Soft tissue examination - No significant findings
 Hard tissue examination
Dentition
Teeth present
Missing
Labially erupted
Rotated
Permanent
17 16 15 14 13 12 11 22 23 24 25 26 27
47 46 45 44 43 42 41 31 32 33 34 35 36 37
21
23
22

9. PROVISIONAL DIAGNOSIS
Class 1 malocclusion with partially edentulous maxillary arch in relation to 21
Labially erupted 23
Rotated 22

10. INVESTIGATIONS
OPG

11.  Vitality tests
TOOTH ELECTRIC PULP TEST COLD TEST
31 NEGATIVE NEGATIVE
32 33 41 42 43 DELAYED DELAYED

12. FINAL DIAGNOSIS
Radicular cyst irt 31 32 33 41 42 43
Partially edentulous maxillary arch in relation to 21
Rotated 22
Labially erupted 23

13. DIFFERENTIAL DIAGNOSIS
Lateral periodontal cyst Dentigerous cyst
Odontogenic
keratocyst
Aneurysmal bone
cyst
Traumatic bone
cyst

14. TREATMENT PLAN
Root canal treatment irt 31 32 33 41 42 43
Othodontic derotation of 22
Replacement of missing tooth irt 21

15. DISCUSSION
RADICULAR CYST
 ‘Cyst’……Greek word, ‘Kystis’………‘sac or bladder’
 A Cyst is a pathological cavity having fluid, semifluid or gaseous contents
and which is not created by the accumulation of pus (Kramer)

16. CLASSIFICATION

17.  Other names Apical Periodontal Cyst
Periapical cyst
Root end cyst
 It is a true cyst, since the lesion consists of a pathologic cavity lined by epithelium
and is often fluid-filled
 Radicular or periapical cyst is the most common odontogenic cystic lesion of
inflammatory origin, derived from Cell rests of Malassez that proliferate in
response to inflammation , occurring in relation to the apex of a nonvital tooth.

18. TYPES OF RADICULAR CYSTS
• Apical 70%
• Lateral 20%
• Residual 10%

19. ETIOLOGY
 Trauma
 Dental caries
 Nonvital tooth
INCIDENCE
 52% to 68% percent of all types of jaw cysts.
 Age: third, fourth and fifth decade of life.
 Sex: males > females

20. PATHOGENESIS
 Initiation
 Proliferation
 Cystification
 Enlargement

21. HISTOPATHOLOGY

22. RADIOLOGICAL FEATURES
 Unilocular, round shaped radiolucent areas
 Radiopaque border

23. A preliminary clinical diagnosis of a periapical cyst can be made based on the
following
 (a) The periapical lesion is involved with one or more non-vital teeth,
 (b) The lesion is greater than 200 mm2 in size,
 (c) The lesion is seen radiographically as a circumscribed, well-defined radiolucent
area bound by a thin radiopaque line
 (d) It produces a straw-colored fluid upon aspiration or as drainage through an
accessed root canal system
Eversole LR. Clinical outline of oral pathology: diagnosis and treatment, 2nd ed.
Philadelphia: Lea and Febiger 1984;203-259.

24. The treatment of the cysts can be
Nonsurgical management
Surgical management
 marsupialization
 enucleation
.

25. The factors that determine the choice of treatment
 Age of the patient
 Extension of the lesion
 Relation with noble structures
 Origin
 Clinical characteristics of the lesion,
 Systemic condition of the patient
Narula H, Ahuja B, Yeluri R, Baliga S, Munshi AK. Conservative non-surgical management of
an infected radicular cyst. Contemporary clinical dentistry. 2011 Oct;2(4):368

26. The nonsurgical treatment options available to manage periapical cysts
 Conservative RCT with calcium hydroxide as intra-canal medicament,
 Active nonsurgical decompression technique,
 Aspiration and irrigation technique,
 Lesion sterilization and repair therapy and
 Apexum procedure
Sood N, Maheshwari N, Gothi R, Sood N. Treatment of large periapical cyst like lesion: a
noninvasive approach: a report of two cases. International Journal of Clinical Pediatric
Dentistry. 2015 May;8(2):133.

27. Active nonsurgical
decompression technique
Aspiration and irrigation
technique

28. Lesion sterilization and repair
therapy
Apexum procedure

29. Sood N et al (2015) have successfully treated 2 cases of Large Periapical Cyst Like
lesions by Noninvasive Approach and stated that nonsurgical approach should always
be adopted before resorting to surgery.
Sood N, Maheshwari N, Gothi R, Sood N. Treatment of Large Periapical Cyst Like Lesion: A
Noninvasive Approach: A Report of Two Cases. Int J Clin Pediatr Dent 2015;8(2):133-137

30.  Deepakraj Dandotikar et al (2013) in their case report of Nonsurgical Management of a
Periapical Cyst, suggested that A well defined treatment protocol must be used that
eliminates their etiology in the root canal system rather than their product, apical true cyst
Dandotikar D, Peddi R, Lakhani B, Lata K, Mathur A, Chowdary U K. Nonsurgical
Management of a Periapical Cyst: A Case Report. J Int Oral Health 2013; 5(3):79-84

31.  Shweta Dwivedi et al (2021) managed a case of a large radicular cyst by non-surgical
endodontic approach, concluded that Surgical treatment is indicated only when nonsurgical
treatment is unlikely to provide the desired outcome
Dwivedi S, Dwivedi CD, Chaturvedi TP, Baranwal HC. Management of a large radicular
cyst: A non-surgical endodontic approach. Saudi Endodontic Journal. 2021 Sep 1;4(3):145

32.  Maity I et al (2014) in their clinical study found that Single visit nonsurgical
endodontic therapy for periapical cysts was successful in selected cases
Maity I, Meena N, Kumari RA. Single visit nonsurgical endodontic therapy for
periapical cysts: A clinical study. Contemporary clinical dentistry. 2014 Apr;5(2):195.

34. TREATMENT DONE
First appointment
Case history recorded in detail
Investigations ..vitality tests , opg
Medication. …Amoxicillin 500mg bd, hifenac 400mg tid for 1 week

35. Under local anesthesia, access opening was done irt 31 32 33 41 42 43
Necrotic pulp tissue was extirpated, followed by copious irrigation with 3%
sodium hypochlorite and normal saline
Working length determined
Calcium hydroxide with iodoform paste ( metapex ) was injected up to the cystic
lesion through the root canal irt 31 and no intracanal medicament irt remaining
teeth
Access cavity was sealed for a period of 1 week with an intermediate restorative
material

36. After 7 days, patient was recalled, Canals were cleaned and shaped by Protaper
hand files
Irrigation done using 3 % sodium hypochlorite and normal saline
Triple antibiotic paste was placed as intracanal medicament and access cavity
was sealed intermediate restorative material for a period of 3 weeks
The patient was kept on follow up

37. After 1 month of commencement of treatment, Complete debridement and
irrigation of the root canal was done, obturation completed with 6% gutta-
percha
Access cavity is closed by using composite restoration
Patient is put on regular recall visits

38. POST OP OPG

39. CONCLUSION
 Modern concept of medicine emphasizes prevention and reversal of diseases,
minimum invasive and less time-consuming procedure
 Only when these attempts fail, we would take on the unfavorable approaches,
i.e., surgical intervention and restoration with artificial prosthesis.
 During the past few years there has been gradual change in the attitude to
surgical treatment of periapical lesions
 In the present case, the non surgical management of radicular cyst, is
considered an efficient and feasible alternative that can recover the esthetics
and function, instituting positive attitude towards dental treatment in a
growing child

40. REFERENCES
 Sood N, Maheshwari N, Gothi R, Sood N. Treatment of Large Periapical Cyst Like
Lesion: A Noninvasive Approach: A Report of Two Cases. Int J Clin Pediatr Dent
2015;8(2):133-137
 Bhaskar SN. Nonsurgical resolution of radicular cysts. Oral Surgery, Oral Medicine,
Oral Pathology. 1972 Sep 1;34(3):458-68.
 Dandotikar D, Peddi R, Lakhani B, Lata K, Mathur A, Chowdary U K. Nonsurgical
Management of a Periapical Cyst: A Case Report. J Int Oral Health 2013; 5(3):79-84.
 Dwivedi S, Dwivedi CD, Chaturvedi TP, Baranwal HC. Management of a large
radicular cyst: A non-surgical endodontic approach. Saudi Endodontic Journal. 2014
Sep 1;4(3):145
 Raisingani D. Apexum: A minimum invasive procedure. International Journal of
Clinical Pediatric Dentistry. 2011 Sep;4(3):224.

41.  Mejia JL, Donado JE, Basrani B. Active nonsurgical decompression of large
periapical lesions–3 case reports. J Can Dent Assoc. 2004 Nov 1;70(10):691-4
 Barodiya A, Thukral R, Solanki SK, Chauhan SP, Singh S. Comparative Evaluation
for Surgical and Non-Surgical Management of Radicular Cyst-An Original
Research. Annals of the Romanian Society for Cell Biology. 2021 Mar 1:6755-60
 Maity I, Meena N, Kumari RA. Single visit nonsurgical endodontic therapy for
periapical cysts: A clinical study. Contemporary clinical dentistry. 2014 Apr;5(2):195
 Shafers text book of oral and maxillofacial pathology
 Sain S, Reshmi J, Anandaraj S, George S, Issac JS, John SA. Lesion sterilization and
tissue repair-current concepts and practices. International journal of clinical pediatric
dentistry. 2018 Sep;11(5):446.