Radicular cyst

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

Transcript of Radicular cyst

  • Data, De Castro, Ghobadyfard, Rohani, Azinfar, Seyed Arab Grp. 3
  • 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.
  • 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.
  • 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.
  • General Data: A.F. 55 y/o Male Married Filipino Roman Catholic Antipolo
  • Left mandibular mass
  • 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
  • 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
  • (-) Hypertension (-) Diabetes Mellitus (-) Allergies to food or medication
  • (-) Hypertension (-) Diabetes Mellitus (-) Cancer
  • 41 pack years Drinks occasionally consuming 3-4/week Denies illicit drug used
  • No cervical lymphadenopathies No mass palpated
  • No gross deformity No tragal tenderness Intact TM, pearl white appearance, non-bulging No ear discharge Non hyperemic canal
  • No gross deformity/deviation No nasal discharge No epistaxis (-) congestion No polyps No masses
  • Presence of mass Presence of swelling
  • Vocal cord equally moving No mass noted No edema Non-hyperemic
  • No mass noted
  • Cyst is a pathological fluid-filled cavity lined by epithelium. o Components of a cyst: Lumen (cavity), Epithelial lining, Wall (capsule)
  • 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.
  • 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.
  • 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.
  • Most common location: (maxilla 3x more affected) o Maxillary anterior region o Maxillary posterior region o Mandibular posterior region o Mandibular anterior region
  • 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.
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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 surf