Pedodontics
P edodontics
PERIAPICAL CYST MANAGEMENT IN A FOURTEEN YEAR OLD
ADOLESCENT
Dr. Priti Yadav Dr. Chanchal Singh
P.G. Student Professor & H.O.D
INTRODUCTION
Cyst is defined as a pathologic cavity lined by epithelium usually containing
fluid or semi-solid material and sometimes air. Odontogenic cysts are derived
from the epithelium associated with the development of dental apparatus and
can arise from 1) Tooth germ 2) Epithelial rests of malassez 3) Reduced enamel
epithelium of a tooth crown 4) Remnants of dental lamina or 5) possibly
the basal layer of oral epithelium.1 A periapical or radicular cyst arises from
epithelial cell rests of Malassez in the periodontal ligament as a consequence
of inflammation following pulpal necrosis of a non-vital tooth. This condition
is usually asymptomatic but can result in a slow-growth tumefaction in the
affected region.2 Many radicular cysts are symptomless and are discovered
with periapical radiographs of teeth with non-vital pulps. The treatment of the
cysts can be either non-surgical management or surgical management being
either marsupialization or enucleation depending on the size and localization
of the lesion, the bone integrity of the cystic wall and its proximity to vital
structures.3 Shear M and Geward GR also reported that periapical cyst
has high incidence in the maxillary anterior region, presumably as a result
of trauma.4 This case report presents a case of surgical management of a
periapical cyst associated with non-vital permanent right maxillary central and
lateral incisors in a 14 year old.
CASE REPORT
A 14 year old male reported to the Department of Pedodontics and Preventive
Dentistry, K. D. Dental College and Hospital, Mathura, with a complaint of
pus discharge from upper front tooth region and bad smell from the mouth
for past two year. Past history revealed that he had trauma two year before
in maxillary anterior region for which no treatment was sought. Post trauma
he had dull intermittent pain in relation to the upper anteriors which subsided
without medication. During examination, he was found to be in good general
and physical health. On intraoral examination, Ellis class IV fracture was
present with maxillary right central incisor and vitality test gave a negative
28 GUIDENT  |  Your Guide on the path of Dentistry
July 2016
A Case Report
Department of Pedodontics & Preventive Dentistry
K.D. Dental College and Hospital, Mathura, India.
Periapical cysts are most common odontogenic cyst
located at the apex of carious or traumatized tooth. It
arises from epithelial remnants stimulated to proliferate
by an inflammatory process originating from pulpal
necrosis of a non-vital tooth. Radiographically, the
classical description of the lesion is a round or oval,
well-circumscribed radiolucent image involving the
apex of single or multiple teeth. Cyst can be managed
surgically and or non-surgically depending on site and
size of cyst. This case report deals with a fourteen year
old adolescent with periapical cyst associated with
maxillary right central and lateral incisors that was
successfully managed with single sitting root canal
therapy (RCT) along with surgical enucleation of the
cyst.
Keywords: Periapical cyst, root canal treatment, cyst
enucleation
response in relation to maxillary right central and lateral incisor (figure 1). An
intraoral periapical radiograph of maxillary central and lateral incisor revealed
a well-circumscribed periapical radiolucency of about 3x2 cm in dimension,
involving both the roots apices and extending from mesial aspect of root
apex of right canine to left central incisor, suggesting a cystic lesion (figure
2). Based on the history, clinical examination and radiographic examination, a
provisional diagnosis of Ellis class IV fracture of maxillary right central incisor
associated with cyst involving root apex of both right central and lateral
incisor was made but the final call for type of cyst was left to histopathologic
report. Treatment plan comprised of RCT with right central and lateral incisor
 July 2016

and cyst enucleation. With the consent of the parents, the endodontic therapy
Pedodontics
P edodontics
was carried out followed by cyst enucleation procedure. Under all aseptic
conditions local anesthesia was administered and crevicular incision was
given on labial aspect extending from right canine to left central incisor to
reflect full thickness flap that exposed a wide labial bone defect. Cyst lining
was excavated along with its content followed by thorough curettage (figure
3 and 4). Flap closure was done using 3-0 silk suture. Specimen was sent for
histopathological examination which confirmed periapical cyst. Considering
patient’s young age and good health, bone graft was not used. After a week,
patient was recalled for suture removal and a periapical radiograph was taken
(figure 5). Esthetic restoration with composite was done with right central
and lateral incisor after a week (figure 6). This case is a good example of a
large lesion been treated with conventional RCT and cyst enucleation without
the use of materials which enhance bone regeneration like Platelet Rich Fibrin
(PRF) G-bone (Synthetic Granules and blocks made of Multiphasic Calcium
Hydroxyapatite in low crystalline form). Intraoral periapical radiograph for
successive two years postoperatively was taken which revealed regression of Figure 3: Enaculation of bony defect and cystic lesion
the cystic lesion and formation of bony trabaculae (figure 7, 8 and 9).

Figure 1: Front view of fractured right maxillary central incisor

Figure 4: Excavated cystic lining

Figure 2: IOPA radiograph showing cyst in relation to maxillary central Figure 5: IOPA radiograph after one week showing progressive healing
and lateral incisor

Your Guide on the path of Dentistry  |  GUIDENT 29

Pedodontics
P edodontics
Figure 6: Esthetic restoration done in maxillary right central incisor
Figure 7: IOPA radiograph after 6 months showing progressive healing
Figure 8: IOPA radiograph after 12 months showing progressive healing
30 GUIDENT  |  Your Guide on the path of Dentistry
July 2016
Figure 9: IOPA radiograph after 24 months showing healthy bony
trabaculae
DISCUSSION
A cyst is a pathologic closed cavity lined by an epithelium that can occur
anywhere in the body and vary in size and contents such as blood, seroma,
semisolid or gaseous contents, but is not normally filled with pus, unless it is
infected. Cysts constitute about 17% of all the tissue specimens submitted
to oral pathology biopsy services. The periapical cyst is the most common
odontogenic cyst (52.3–70.7% of all odontogenic cysts) followed by the
dentigerous cyst (16.6–21.3% of all odontogenic cysts) and odontogenic
keratocyst (5.4–17.4% of all odontogenic cysts).5 Periapical cysts are
odontogenic cysts that are derived from the inflammatory activation of
epithelial root sheath residues (cell rests of Malassez). They are inflammatory
in nature and usually arise within a periapical granuloma relating to stimulation
resulting from a necrotic tooth.6–8 They are most commonly associated with
permanent teeth and are rare in the primary teeth.9 The choice of treatment
may be determined by factors such as the extension of the lesion, relation
with noble structures, origin, and clinical characteristics of the lesion, and
co-operation and systemic condition of the patient. The treatment of these
cysts is still under discussion and many professionals opt for a conservative
treatment by means of endodontic therapy alone. However, in large lesions
the endodontic treatment alone is not efficient and is associated with
decompression, marsupialization or enucleation.10–12 In this regard, it is
suggested that the treatment of periapical cyst should be defined according
to the clinical and radiographic evaluations of each case.
CONCLUSION
The clinical case reported in this article was managed successfully by
endodontic therapy with emphasis on thorough debridment, disinfection and
three dimensional obturation of the root canal system which was followed by
surgical enucleation of the cyst. Two year follow up and radiographs showed
healing of lesion with bony trabaculae formation.
References are available on request
1
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