EXTENSIVE RADICULAR CYST OF THE MANDIBLE: A RARE CASE REPORT

Maxillofacial surgery

EXTENSIVE RADICULAR CYST OF THE MANDIBLE:

A RARE CASE REPORT

Gokul VENKATESHWAR1, Charu GIROTRA2, Geetanjali MANDLIK1,

Mukul PADHYE1, Vinit PANDHI3, Shruti KAKKAR3

1. Dr., M.D.S., Prof., Dept. Oral Maxillofacial Surgery, Pad.Dr.DY Patil Dental College, Navi Mumbai, India
2. Dr., M.D.S., Assoc. Prof., Dept. Oral Maxillofacial Surgery, Pad.Dr.DY Patil Dental College, Navi Mumbai, India
3. Dr., Post Graduate Student, Dept. Oral Maxillofacial Surgery, Pad.Dr.DY Patil Dental College, Navi Mumbai, India
Corresponding author: Shruti Kakkar, e-mail: drshrutikakkar@hotmail.com

Abstract the swelling about a month ago, during which it

The radicular cyst is the most common inflammatory
slowly increased to its current size. The patient
odontogenic cystic lesion of the jaws. It usually originates had a fall and blunt trauma to the chin about
as a sequel to a periapical inflammatory process, following 10 years ago, for which no treatment was taken,
chemical, physical or bacterial injury. Due to its chronic as well as a history of extraction of carious
etiology, the cyst usually appears towards the later stage
of life. It has a male sex predilection, with the maxillary 37 fifteen years ago. No obvious swelling or
anterior region as the most common site of involvement. facial asymmetry was noted on extraoral exami-
This article reports a rare case of a large radicular cyst in the nation. No sinus or fistula was evident extaorally.
mandible, its management and follow up along one year.
Keywords: radicular cyst, odontogenic cyst, bismuth iodo-
Regional lymph nodes were non-enlarged, non-
form paraffin paste, enucleation, epithelial cell rests of Malassez. palpable.
On intraoral examination, a firm, diffuse, non-
INTRODUCTION reducible swelling was noted, extending from 33
to 43, obliterating the mandibular labial vesti-
bule. Blanching of the oral mucosa was seen
The radicular cyst is the most common odon- overlying the swelling. Dull pain was elicited on
togenic innflammation of the jaws. It originates palpation. All teeth were vital except 34, none of
from the epithelial cell rests of the Malassez the involved teeth being mobile, and pain on per-
periodontal ligament or of the surrounding bone, cussion was negative. No paraesthesia was
secondary to inflammation [1]. It is a slow grow- noted.
ing cyst with a tendency towards bone resorp- Considering the extensive nature of the lesion,
tion, generally 0.5 to 1 cm in size, even if a few Plain and Contrast Computed Tomographic
cases of large cysts have been occasionally scans of the facial bones were made in addition
reported. The radicular cyst commonly shows to the regular panoramic and occlusal radio-
a male predilection with maxillary anterior graphs. On radiographic examination, a large
region as its prevalent site of involvement. unilocular radiolucency was noted, extending
Radicular cysts have been regularly associated from 36 to 46, with root resorption of all involved
with carious, non-vital teeth or teeth with a his- teeth and well-defined, well-corticated borders.
tory of trauma [2]. The case of an extensive man-
The inferior border of the mandible was intact.
dibular radicular cyst showing some atypical
33 was slightly displaced. Buccal and lingual cor-
features is presented herewith.
tical plates were intact, but expansion of the buc-
cal cortical plate was seen in the 33 to 43 region.
CASE REPORT Based on a detailed history, careful clinical
examination and radiologic investigations, the
A 52 year-old male patient reported to the following differential diagnosis of the current
Department of Oral and Maxillofacial surgery lesion has been established.
with a complaint of painless swelling in the According to Wood and Goaz [3], if a well-
lower front region of the jaw. The patient noticed defined radiolucency is observed at the apex of

International Journal of Medical Dentistry 71

Gokul Venkateshwar, Charu Girotra, Geetanjali Mandlik, Mukul Padhye, Vinit Pandhi, Shruti Kakkar

an untreated asymptomatic tooth with a non- The peripheral cement-osseous dysplasia is

vital or diseased pulp, and if the anatomic struc- by far the most common fibro-cemento-osseous
tures can be ruled out, the radiolucency is a lesion. In the early stage of development, PCOD
dental granuloma or a radicular cyst in approxi- occurs as a somewhat rounded radiolucency,
mately 90% of the cases. Even if these entities with well-defined borders, associated with teeth
cannot be distinguished by radiographic features having vital pulps. The lesion has a clear female
alone, if radiolucency is 1.6 cm or more in diame­ predilection and is rarely recorded before
ter, it is more likely to be a cyst [4,5]. The radicu- 40 years of age. It is commonly seen in the man-
lar cyst is a common inflammatory odontogenic dibular anterior region. It is unusual for a PCOD
cyst of the jaws, originating from the epithelial to become large enough to produce a detectable
cell rests of Malassez periodontal ligament or of cortical expansion.
the surrounding bone, secondary to inflamma- The cemento-ossifying fibroma is a very com-
tion. It is a slow growing cyst with a tendency mon lesion of the mandible found in the premo-
towards bone resorption, generally 0.5 to 1 cm lar molar region at an average age of 30 years,
in size, however a few cases of large cysts have with no specific gender predilection. Initially
been occasionally reported. The radicular cyst radiolucent, the lesion becomes radio-opaque
commonly shows a male predilection, with the within around 6 years, due to the progressive
maxillary anterior region as its prevalent site of deposition of cementum and spicules of bone.
involvement. Radicular cysts have been regu- A matured lesion appears as a well-defined radi-
larly associated with carious, non-vital teeth or opacity, usually surrounded by uniform radio-
with teeth associated with a history of trauma. lucency.
The traumatic cyst is an idiopathic cavity The odontogenic keratocyst, forming 5-11% of
which occurs in other bones as well as in jaws, all jaw cysts, frequently appears as a well-defined
being classified as a false cyst – once it has no radiolucency, occurring more commonly in the
epithelial lining. Classically, the TBC, located mandible and largely affecting the male popula-
above the mandibular canal, is usually round to tion. In Shafer’s series [6], 7.8% of all jaw cysts,
oval, with contoured, well-defined borders. 8.5% of the dentigerous cysts and 0.9% of all
Quite often, the superior border extends between radicular cysts are odontogenic keratocysts.
the roots of the teeth, giving a scalloped appear- The unicystic ameloblastoma formed inside
ance. Usually, it does not exceed 3cm in diame- the walls of a dentigerous cyst is the second most
ter, even if lesions have been reported in the common pericoronal radiolucency. Amelo-
entire ramus and body. Generally seen in patients blastma represent approximately 11 to 13% of all
under 30 years, it shows a slight male predomi- odontogenic tumors. Usually locally invasive,
nance [2]. initially asymptomatic, it causes cortical expan-
The central giant cell granuloma/lesion may sion and may perforate the cortices. It may also
occur initially as a solitary, cyst-like radiolucency; appear as an unilocular cyst or as a multilocular
as it grows larger, it frequently becomes a soap soap-bubble or honeycomb variety. Generally, it
bubble type of multilocular radiolucency. The occurs equally in men and women under 30 years
lesion is painless and grows slowly by expand- of age. It may be also associated with the residual
ing and thinning the cortical plates, but only cyst, radicular cyst, globulomaxillary cyst and
rarely it perforates into the soft tissue. An primordial cyst, appearing as a slowly enlarging
expanding lesion may cause some teeth migra- lesion causing cortical expansion.
tion, and root resorption has been reported. His- Aspiration biopsy revealed straw colored
topathologically, hemosidrin is seen as scattering fluid and shiny cholesterol crystals, suggestive
throughout the lesion, along with many irregu- of a radicular cyst or of an infected unicystic
larly shaped giant cells. Also, an osteoid may be ameloblastoma; consequently, an incisional
often seen within the lesional tissue. Results of biopsy was taken, which revealed odontogenic
serum chemistry tests should be studied to epithelial lining composed of stratified squa-
exclude the possibility of a giant cell lesion of mous epithelium. The connective tissue capsule
hyperparathyroidism. showed mild inflammatory cell infiltrate with

72 volume 17 • issue 1 January / March 2013 • pp. 71-75

 EXTENSIVE RADICULAR CYST OF THE MANDIBLE: A RARE CASE REPORT

numerous cholesterol clefts, suggestive of a and cultured cyst explants from radicular cysts,
radicular cyst. keratocysts and follicular cysts, showed high
Following clinical, radiologic and histopatho- levels of endotoxins in radicular cysts, as com-
logic examination, the lesion was diagnosed as a pared to other cyst types.
radicular cyst, and a treatment plan was formu- In the second phase, the cyst cavity comes to
lated. All involved teeth – from 36 to 46 – were be lined by the proliferating odontogenic epithe-
endodontically-treated. Under general anesthe- lium. A widely accepted theory postulated that
sia, in sterile conditions, an intraoral crevicular a cyst cavity is formed within a proliferating epi-
incision was taken from 37 to 47, with left and thelial mass in an apical granuloma by degene­
right releasing incisions posterior to 37 and 47, ration and death of cells in the centre. Grupe
respectively. The full thickness mucoperiosteal et al. [14] demonstrated high levels of acid phos-
flap was raised, and anterior buccal corticotomy phatase activity in the central cells of apical gran-
was carried out. Cystic legion was enucleated ulomas, while Summers [15] found a weak
in toto, sparing the inferior alveolar nerve, which proteolytic activity present centrally within the
was displaced along the inferior border of the proliferating epithelium. Both studies suggest
mandible. Apicotomy of the involved teeth was that these cells are undergoing autolysis.
done and peripheral ostectomy was carried out. The third phase of growth and enlargement
A bismuth Iodoform paraffin paste (BIPP) pack has been considerably researched over time.
was placed for dead space management. Closure Toller suggested that the contents of cystic cavity
was done, leaving a small window for the BIPP are subjected to an osmotic imbalance with the
surrounding tissues, because of the absence of
pack in the region of 31, 32.
lymphatic drainage, whereas Main felt that the
Post-operatively, after 2 weeks, the BIPP pack
radicular cyst fluid was essentially an inflamma-
was reduced in size weekly, along 4 weeks, and
tory exudate. Skaug [16] also commented that
changed once thereafter, carrying out a similar
the cyst walls have many layers of diverse func-
procedure as above. Excisional biopsy has also
tions: vascular endothelium, basement mem-
confirmed the diagnosis of radicular cyst. New
branes, ground substance and cyst wall
bone formation was noted beginning in the epithelium. Studies performed by Toller [17] and
region of 36 and 46. Skaug [18] also confirmed that intracystic pres-
sure was inversely correlated to cyst size and
DISCUSSION concluded that increased pressure played a piv-
otal role in early cyst growth.
Odontogenic cysts constitute frequent benign Pulpal necrosis leading to inflammation
lesions of the jaw bones, due to the ubiquous appears as the most frequent etiology of the
presence of epithelial rests after odontogenesis radicular cyst [2]. A lesser known but likely
[1]. Radicular cysts appear as the most common cause of pulpal necrosis reported in literature is
of all odontogenic cysts, with an incidence traumatic injury to teeth. In our case, none of the
between 50 and 60%, as described by Tay (50.7%) associated teeth were found to be carious, while
[7], Ochsenius et al. (50.7%) [8], Shear et al. (52.3%) only one left mandibular first premolar was
[9] etc., while Silvia et al. [10] found an incidence found to be non-vital but non-carious. Patient
of 84.5%, and Sharifian et al. [11] reported an inci- however did report blunt trauma to the chin
dence of 37.9%. about ten years ago. No injury or bleeding was
reported and no treatment was taken at that
The pathogenesis of radicular cyst is com-
time. Thus, significant trauma 10 years ago
monly considered as occurring under three
appears to have initiated the pathology.
phases: initiation, cyst formation and enlarge-
In the literature, most cases of radicular cyst
ment [12]. The epithelial cell rests of Malassez in
have been described in the anterior maxilla.
the periodontal ligament begin to proliferate by
Some possible reasons reported are: the spongy
inflammation, as a result of the necrotic debris
nature of the maxillary bone and reluctance to
and bacterial antigens derived from the dead
extract anterior teeth, the over retention of which
pulp. Meghji et al. [13], who studied cyst fluids leads to cyst formation. This prevalence has been

International Journal of Medical Dentistry 73

Gokul Venkateshwar, Charu Girotra, Geetanjali Mandlik, Mukul Padhye, Vinit Pandhi, Shruti Kakkar

confirmed by many studies, including those of

Ramchandra et al. [1], Silvia et al. [10], Sharifian
[11]. Very few studies, like those of Meningrad
et al. [19] and Koseglu et al. [20] contradict the
above findings, sustaining that the mandibular
radicular cyst is more common.
Most of the cases of radicular cyst show a clear
male predilection, which explains their increased
tendency to trauma, the poor oral hygiene, caries
and retention of carious teeth. Sharifian et al. [11]
found that the radicular cyst is 1.3 times more
frequent in men, while Silvia et al. [10] found
about 2/3rd of the cysts in males. Figure 2. Intra-operative enucleated cystic lining
Generally, radicular cysts are small periapical
lesions associated with one or more carious teeth,
attaining 0.1 cm to 1 cm, even if a few long stand-
ing large radicular cysts larger than 5 cm have
been reported [2]. This cyst is an unusually large
mandibular cyst extending bilaterally from from
36 to 46, which is an extremely rare finding.
Another striking feature is the absence of infe-
rior alveolar nerve paraesthesia. During surgery,
the inferior alveolar nerve was displaced along
the inferior border of the mandible, which was
carefully preserved. Figure 3. Cystic lining
In our case, root canal treatment of all involved
teeth was performed, along with enucleation of
the lesion, sparing of the inferior alveolar nerve
and of the mental nerve, with a Bismuth Iodo-
form Paraffin paste (BIPP) pack in situ, to facili-
tate bone formation and prevent dead space
formation. In order to achieve a periapical seal,
apicoectomy with retrograde filling was done in
all involved teeth, from 36 to 46.
The case report here presented is an unusually Figure 4: Microscopic picture showing odontogenic
large mandibular radicular cyst, therefore, a rare stratified epithelium (a) and cholesterol clefts (b)
documentation in literature.

Figure 5: 11 months post-operative

Figure 1. Pre-operative orthopantomograph
orthopantomograph

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 EXTENSIVE RADICULAR CYST OF THE MANDIBLE: A RARE CASE REPORT

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