Dr Bhavik Miyani, Resident Doctor in Department of Oral & Maxillofacial Surgery, NPDCH, SPU, Visnagar.

1. Presented By:
Dr. Bhavik Miyani
Guided By:
Dr Anil Managutti
Dr Shailesh Menat
Dr Rushit Patel
Dr Nirav Patel
Case of Radicular Cyst
Department of OMFS, NPDCH, SPU, Visnagar.

2. CONTENT
 Case report
 Discussion
 Conclusion
 References

3. CASE REPORT
NAME :- Nehal ben Patel
AGE/SEX :- 33 Years/ Female
OCCUPATION :- Teacher
ADDRESS :- Unjha
OPD NO. :- 24234-H

4. CHIEF COMPLAINT
• Patient complaint of non healing ulcer irt with lower
chin region since 8 years and pain since 1 month.

5. HISTORY OF PRESENT ILLNESS
 Patient was relatively asymptomatic before 8 years.
 Then she developed one boil on lower anterior region of chin. she noticed pus
like white thick purulent material discharging from ulcer.
 After two month she visited to Dermatologist at private clinic at Visnagar where
they diagnosed with mole and given laser therapy.
 Then boil is healed completely.
 Then after 8 month recurrence of boil at same site occurs.
 Then she referred to surgeon where they advised surgical removal of lesion and
she underwent excision of lesion under local anesthesia.

6. HISTORY OF PRESENT ILLNESS
After this lesion is subsided till 8 months.
Then she developed pain irt with same region which mild,
continues and dull aching type with no associated symptoms and
then she came to the department of OMFS, NPDCH with above
mentioned complain.
H/O- Trauma at the age of 15 years in mandibular teeth region.
No H/O- Fever, malaise or loss of appetite.

7.  PAST MEDICAL HISTORY :-
- No H/O previous hospitalization
- No H/O any systemic diseases like Hypertension,
Diabetes Mellitus, Hepatitis
 PAST DENTAL HISTORY :-
- No relevant past dental history
 DRUG HISTORY :-
- No relevant drug allergy
 FAMILY HISTORY :-
- No relevant family history

8. PERSONAL HISTORY :-
- Habits :-No any harmful habit.
- Diet :- Vegetarian
- Marital status :- Married
- Brushing :- Once a day with toothbrush

9. • Conscious
• Cooperative
• Well Oriented to time, place and person
• Built :-Well built
• Nourishment :- Well nourished
• Gait :- Normal
 Vital signs :-
Temperature: Afebrile
Blood pressure: 134/86 mmHg
Pulse rate: 78beats/min
Respiratory rate: 16 cycles/min
GENERAL EXAMINATION

10. • Face :- No gross facial asymmetry.
• Skin and soft tissue :- NAD.
• Lips :- Competent.
• Jaw movement :- No jaw deviation while opening or closing jaw.
• TMJ :- NAD.
• Mouth opening :- 38 mm.
1. EXTRA- ORAL EXAMINATION

11. Swelling Examination
• Inspection:
• A solitary, well defined, round shaped measuring around 1*1 cm in
size swelling present over mandibular chin region having fistula.
• Palpation:
• All the inspector findings are confirmed by palpation. Swelling was
non tender, soft, overlying temperature normal.

12. EXTRA- ORAL EXAMINATION

13. • Present teeth- 11-17,21-27,31-37,41-47.
• Occlusion- Angle’s Class 1 relationship bilaterally.
2. INTRA-ORAL EXAMINATION
Hard Tissue Examination

14. Soft Tissue Examination
• Buccal Mucosa – NAD.
• Labial Mucosa – NAD.
• Palate – NAD.
• Gingiva – NAD.
• Floor of the mouth-NAD.

15. INTRA- ORAL EXAMINATION

16. INTRA- ORAL EXAMINATION

17. PROVISIONAL DIAGNOSIS
1. Periapical cyst i.r.t. 31,41.

18. (1) Mandibular Occlusal View
(2) IOPA i.r.t. 31,41
(3) Chest X-Ray
(4) CT-SCAN of neck
INVESTIGATIONS

19. INVESTIGATIONS
Occlusal view IOPA

20. Chest X- RAY

21. CT-NECK
OPG is showing fracture line starting from crest
of alveolar ridge between 33 and 34 tooth and passing
inferior and backward direction involving inferior border
of mandible suggestive of Parasymphysis fracture. There
is also presence of fracture line passing from
48 inferior and backward direction involving basal bone
suggestive of simple fracture.

22. FINAL DIAGNOSIS
1) Infected Radicular cyst i.r.t. 31,41

23. TREATMENT PLAN
1. Extraction of 31,41 followed by fistulectomy.
2. Medications and follow up.

24. TREATMENT GIVEN

27.  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.
INTRODUCTION
DISCUSSION

28.  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.

29. o Components of a cyst: Lumen (cavity), Epithelial lining, Wall

31.  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.
RADICULAR CYST

32. 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.

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

34. • 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.
CLINICAL FEATURES

36. HISTOPATHOLOGY

37. 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.
HISTOPATHOLOGY
Lumen

38. o Non-keratinized stratified squamous epithelium.
o Lacks a well-defined basal cell layer.
o Thick, irregular, hyperplasti or net like forming
rings & arcades.
o Hyaline bodies (Rushton bodies) may be found
o Mucous cells – as a result of metaplasia.
Epithelial lining

39. • 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 haemorrhage
o Are of no clinical significance
• Russel bodies: refractile and spherical
intracellular bodies representing Gamma
Globulin.

40. • 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.
RADIOGRAPHIC SIGNS

42. 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 Marsupialization- 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
MANAGEMENT

43. Patient 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.

44. • 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.
CONCLUSION

45. • 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.

46. 1. Cawson’s Essentials of Oral Pathology & Oral Medicine- 7th edition.
2. Oral and Maxillofacial Medicine (Crispian Scully CBE).
3. Shafer’s Contemporary Oral and Maxillofacial Pathology.
4. Lucas’s pathology of tumors of the oral tissues- 5th edition.
REFERENCES