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

1.  
Data, De Castro, Ghobadyfard, Rohani, Azinfar, Seyed
Arab
Grp. 3

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.  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.  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. General Data:
 A.F.
 55 y/o
 Male
 Married
 Filipino
 Roman Catholic
 Antipolo

6.  Left mandibular mass

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. 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. (-) Hypertension
(-) Diabetes Mellitus
(-) Allergies to food or medication

10. (-) Hypertension
(-) Diabetes Mellitus
(-) Cancer

11.  41 pack years
 Drinks occasionally consuming 3-4/week
 Denies illicit drug used

12. 

13.  No cervical
lymphadenopathies
 No mass palpated

16.  No gross deformity
 No tragal tenderness
 Intact TM, pearl white
appearance, non-bulging
 No ear discharge
 Non hyperemic canal

17.  No gross deformity/deviation
 No nasal discharge
 No epistaxis
 (-) congestion
 No polyps
 No masses

18.  Presence of mass
 Presence of swelling

22.  Vocal cord equally moving
 No mass noted
 No edema
 Non-hyperemic

23.  No mass noted

24. 

26. 

27.  Cyst is a pathological fluid-filled cavity lined by
epithelium.
o Components of a cyst: Lumen (cavity), Epithelial lining, Wall
(capsule)

28.  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.

30.  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.

31.  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.

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

33.  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.

36.  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

37.  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

39.  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

41.  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

42.  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

43.  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

46.  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

47.  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.

48. 

50.  It can develop even after years after tooth extraction and
is responsible for ameloblatomas that develop on
patients older than 30 years.

51. 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

52. 

53.  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

54.  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