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Contemp Clin Dent. 2011 Jan-Mar; 2(1): 59–62.

doi: 10.410309!6-23!".!9295

#MC$D: #MC32201!9

An unusual case report of bilateral mandibular radicular cysts

%i&anta '. Joi* '. +. ',an* and M. M. a/appa

 ,tor inormation  Cop&rit and i/ene inormation

i arti/le a een /ited & oter arti/le in #MC.

Abstract

+o to:

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.2"

#natomically the periapical cysts occur in all tooth$bearing sites of the jaw but are more

freuent in the ma&illary than the mandibular region.!,'"

Radicular cysts can heal spontaneously after endodontic treatment or e&traction.

(owe)er, some authors propose that suspected radicular cysts must be totally enucleated

surgically to remo)e all epithelial remnants.*"

+o to:

Case Report

# !'$year$old girl repoted to the +ept. of edodontics and re)enti)e +entistry with a

complaint of dull pain and swelling in the right posterior mandibular region since past !5

days. The patient had pain in the same region ! year before and had ta-en medication for

that. he had undergone e&traction of the carious mandibular right first molar ' days

 before.

/&traoral e&amination re)ealed a smooth superfacial swelling of about ' 0 2.5 cm

e&tending from the corner of mouth to the angle of mandible and from the infraorbital

margin to the lower border of mandible 1igure !". The swelling was tender and firmwith

egg shell crac-ling on palpation. The inferior border of mandible was intact. The rightsubmandibular lymph nodes were palpable and tender. ntraorally, the e&traction soc-et of 

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the mandibular right first molar 1igure 2" was present and remaining first molars were

grossly carious. 3estibular obliteration and buccal and lingual plate e&pansion was

obser)ed in the area of right body of mandible 1igure 2".

1igure !

re$operati)e e&tra$oral photograph showing right mandibular swelling and facial

asymmetry

1igure 2

re$operati)e intraoral )iew showing )estibular obliteration and e&traction soc-et related

to the mandibular right first molar 

# definite radiolucency was seen in intraoral periapical )iews of the mandibular right and

left first molar regions. The orthopantamograph 47 showed a large, well$defined

unilocular radiolucency with a sclerotic border periapically on the right side e&tending

from the distal of the mandibular second premolar to mesial of the third molar lea)ingabout ! mm of sound bone at the inferior border of mandible. # root piece of the

mandibular right first molar was seen inside the cystic ca)ity as radio$opaue foreign

 body. The mandibular canal was obliterated inferiorly 1igure '". # unilocular, well$

defined radiolucency with a sclerotic border was accidentally found on the left side of

mandible in)ol)ing the roots of first and second molars 1igure '".

1igure '

reoperati)e orthopantamograph showing periapical unilocular radiolucencies in

mandibular right and left first molar regions

1ine needle aspiration cytology 41#97 re)ealed straw coloured fluid. Therefore, based

on patient:s clinical findings, radiographic in)estigations, and 1#9 report, the

 pro)isional diagnosis of bilateral mandibular radicular cysts was made.

The patient was subjected to enucleation of the bilateral cysts under general anaesthesia.

n the right side, a cre)icular 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 e&tracted and the

cyst was remo)ed in toto along with the root piece of the first molar. There was an intact

inferior al)eolar neuro)ascular bundle 1igure *". n the left side, a cre)icular incision

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was made from the distal of the mandibular second premolar to the distal of the second

molar, the mucoperiosteal flap was raised, mandibular first and second molars were

e&tracted, and the cyst was remo)ed in toto 1igure 5". 1laps were repositioned and

sutures were ta-en. The tissue specimens were sent for histopathologial e&amination.

1igure *

ntraoperati)e )iew of enucleation of a cyst and intact neuro)ascular bundle on the right

side

1igure 5ntraoperati)e )iew of enucleation of a cyst on the left side

The surgically e&cised lesion of right side was about *.50' cm in si;e 1igure 6" and left

side was about 20! cm in si;e 1igure <". =oth specimens were creamish brown in colour

and soft in consistency.

1igure 6

hotograph showing the tissue specimen of the right side

1igure <

hotograph showing the tissue specimen of the left side

(istopathological e&amination of the surgical specimens showed non-eratini;ed stratified

suamous epithelial lining with chronic inflammatory cells infiltration, discontinuous

arcading pattern of epithelial lining, hemosiderin pigmentation, and hyaline bodies1igures 1igures8 8 and and>". >". n connecti)e tissue, there were moderate amount of

collagen bundles and blood )essels with infiltration of chronic inflammatory cells

1igures 1igures8 8 and and>". >". #ll these findings were confirmatory for the radicular

cyst.

1igure 8

?icroscopic image of the right side lesion 4( and / stain 0*@7

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1igure >

?icroscopic image of the left side lesion 4( and / stain 0*@7

The patient was recalled after < days for remo)al of suturesA the e&traoral swelling was

resol)ed 1igure !@". The healing on left side was une)entful. n the right side, after

enucleation of the cyst the ca)ity was uite large so to enhance the healing, an acrylic

stent was gi)en to the patient and patient was recalled after e)ery !5 days for chec- up of

healing and necessary adjustments.

1igure !@

ostoperati)e photograph showing the facial asymmetry corrected

e)en months after surgery, e&hibited good amount of bone formation 1igure !!".

9linically, the healing was complete. o, the stent was replaced by remo)able partial

 prosthesis for oral rehabilitation 1igure !2". Right now the patient is on a regular follow

up.

1igure !!

ostoperati)e orthopantamograph ta-en < months after surgery

1igure !2ntraoral )iew showing remo)able partial prosthesis

+o to:

Discussion

# radicular cyst, also -nown as a peri$apical cyst, is usually associated with carious,

non)ital, discolored, or fractured tooth.5,6" The cyst is belie)ed to form by proliferation

of the epithelial cell rests of ?alasse; in inflammed periradicular tissues.<" ts si;e rarely

e&ceeds ! cm and is often seen in patients between'@ and 5@ years old with higher

incidence in the ma&illary anterior region.6,8" n this case, patient:s age, se&, si;e of thecyst, and its bilateral presentation in the mandibular posterior region is considered rare.

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The radicular cyst is usually symptomless and detected incidentally on plain while

in)estigating for other diseases. (owe)er, 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.2,6,>,!@" The swelling is slowly enlarging

and initially bony hard to palpate which later becomes rubbery and fluctuant.2,6"

e)eral treatment options are a)ailable for a radicular cyst such as surgical endodontic

treatment, e&traction of the offending tooth, enucleation with primary closure, and

marsupiali;ation followed by enucleation.6" n this case, surgical enucleation was

 preferred and was performed une)entfully.

To conclude, a radicular cyst is a common condition found in the oral ca)ity. (owe)er, it

usually goes unnoticed and rarely e&ceeds the palpable dimension. This case illustrates a

common condition that occurs in an uncommon age group and location.

+o to:

Acknowledgments

+r. Biran +esai, (ead of the +epartment of ral and ?a&illofacial urgery, B. ?. hah

+ental 9ollege and (ospital, iparia.

+o to:

FootnotesSource of Support: %il

Conflict of Interest: %one de/lared.

+o to:

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 rti/le rom Contemporar& Clini/al Dentitr& are pro7ided ere /o,rte& o Medknow

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