Radicular cyst

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

1. Radicular Cyst Data , De Castro , Ghobadyfard , Rohani , Azinfar , Seyed Arab Grp . 3

2. 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 2 nd premolar area. The patient management comprised surgical enucleation of cystic sac under general anesthesia followed by rehabilitation of the same area.

3. 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.

4. 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.

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

6. Chief Complaint Left mandibular mass

7. History of Present Illness 2 years PTC patient underwent tooth extraction of a carious left lower 2 nd premolar . At that time no noted movable tooth beside the 2 nd 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. 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

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

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

11. Personal & Social History 41 pack years Drinks occasionally consuming 3-4/week Denies illicit drug used

12. Physical Examination

13. Head & Neck No cervical lymphadenopathies No mass palpated

14. Head & Neck

15. Head & Neck

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

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

18. Oral Cavity Presence of mass Presence of swelling

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

20. Posterior Rhinoscopy No mass noted

21. Panoramic X-ray

22. Discussion

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

24. 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.

25. 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 .

26. It is classified as follows: 1 ) Periapical Cyst (70%): These are the radicular cysts which are present at root apex. 2) Lateral Radicular Cyst (20%): These are the radicular cysts which are present at the opening of lateral accessory root canals of offending tooth. 3) Residual Cyst : These are the radicular cysts which remains even after extraction of offending tooth.

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

28. Clinical Features Usually asymptomatic Slowly progressing If infection enters, the swelling becomes painful and rapidly expands Initially swelling is round and hard Later part of the wall is resorbed leaving a soft fluctuant swelling, bluish in color, beneath the mucous membrane When bone has been reduced to egg shell thickness a crackling sensation ( crepitant ) may be felt on pressure.

29. The main factors in the pathogenesis of cyst formation are: Proliferation of epithelial lining and fibrous capsule Hydrostatic pressure of cystic fluid 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

30. Histopathology Lumen: Cyst fluid (watery & opalescent) but sometimes viscid and yellowish Sometimes shimmers with cholesterol crystals (typically rectangular shaped cholesterol crystals with a notched corner is characteristic) Cholesterol crystals are not specific to radicular cysts Protein content of fluid – seen as amorphous eosinophilic material often containing broken-down leucocytes and and cells distended with fat globules

31. Histopathology Epithelial lining: Non-keratinized stratified squamous epithelium Lacks a well-defined ba s al cell layer Thick, irregular, hyperplastic or net like forming rings & arcades Hyaline bodies ( Rushton bodies) may be found Mucous cells – as a result of metaplasia

32. Histopathology Wall/Capsule Composed of collagenous fibrous connective tissue Capsule is vascular and infiltrated by c hronic inflammatory cells Plasma cells are prominent or predominate Russel bodies are often found Pulse or Seed granulomas are often found in cyst wall

33. Histopathology Hyaline bodies ( Rushton bodies): characterized by a hairpin or a slightly-curved shaped, concentric lamination and occasional basophilic mineralization. Are within the epithelium lining Origin believed to be previous hemorrhage Are of no clinical significance Russel bodies: refractile and spherical intracellular bodies representing Gamma Globulin

34. 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: Poorly demarcated borders Background structures become invisible and the defect appears as tunneling PDL space around the involved tooth becomes widened

35. Management Treatment of a tooth with radicular cyst may include: Tooth extraction Endodontic therapy – if the involved non vital tooth is to be retained 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 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

36. 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.

37. Differential Diagnoses

38. Dentigerous Cyst

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

40. 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

41. Conclusion

42. 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 .

43. 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 – 7 th edition Oral and Maxillofacial Medicine ( Crispian Scully CBE) Contemporary Oral and Maxillofacial Pathology – 2 nd edition