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Case Report

Radicular Cyst of The anterior Maxilla: An Insight into the Most Common
Inflammatory Cyst of the Jaws

Abstract Sushmit Koju,

Radicular cyst is believed to be derived from the epithelial cell rests of Malassez. The associated
tooth is nonvital, usually asymptomatic, and may result in swelling, tenderness, tooth mobility, or
other problems with rare possibility of neoplastic transformation of its epithelial lining. The treatment
options include endodontic procedure, extraction of offending tooth, enucleation with primary
closure, and marsupialization. The present report describes the case of a radicular cyst of anterior
maxillary region in a 31‑year‑old male patient, with a detailed description of clinical, radiographic,
histopathologic features, pathogenesis, and its surgical management.
Keywords: Enucleation, maxilla, pathogenesis, radicular cyst
Introduction
The radicular cyst is the most common
inflammatory cyst in the jaw that is of
odontogenic origin.[1] The cyst is believed
to be originated from the epithelial cell rests
of Malassez.[2] It is usually associated with a
tooth having a necrozed pulp. The lesion is
seen mostly in the males during their third and
fifth decades of life.[3] Treatment of radicular
cyst depends on the size of the lesion and can
be treated with a simple conventional therapy
or may require a surgical intervention.[4] The
present report deals with the literature review
of all the aspects of the radicular cyst with an
emphasis on its pathogenesis.
Case Report
A 31‑year‑old male patient presented to
the Department of Oral Medicine and
Radiology, with the chief complaint of
discoloration of the upper front tooth for
4  years. The patient recalled a history of
trauma in the offending tooth 4  years back.
Although the tooth was asymptomatic, it
started to develop blackish discoloration.
Endodontic treatment was done 3  months
back; however, he failed to rehabilitate
the tooth with prosthetic crown. His past
medical history was non-contributory.
Intraoral examination revealed discoloration
in relation to tooth number 11 [FDI] with
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Nitesh Kumar
Chaurasia1,
Vinay Marla2,
Deepa Niroula,
Pratibha Poudel3
Department of Oral Medicine
and Radiology, Dhulikhel
Hospital, 1Department of Oral
and Maxillofacial Surgery,
Dhulikhel Hospital, 3Department
clinically healthy appearing periodontium. of Oral Pathology, Dhulikhel
The tooth 11 showed no signs of mobility Hospital, Nepal, 2Department
of Oral Pathology, Penang
and was nontender to pressure and
International Dental College,
percussion. The patient was advised for Malaysia
intraoral periapical radiograph, anterior
occlusal, and panoramic radiograph for
radiological evaluation.
Radiographs  [Figure  1] revealed a
well‑defined horizontal radiolucency at the
incisal‑third of the crown with reduced
overall height of the crown, suggestive
of attrition. There was a homogenous
radiopacity involving the entire pulp
chamber and the canal, suggestive of prior
endodontic treatment. The radicular and
the periodontal ligament  (PDL) portion
appeared radiographically normal. The
lamina dura was obliterated at the apical
third of the root. There was a well‑defined
radiolucency at the periapical region
with respect to 11 of size approximately
1.25  cm  ×  1  cm with cortical margin;
its epicenter lying 5  mm apical to the Address for correspondence:
root apex. There was no evidence of root Dr. Sushmit Koju,
resorption/displacement of the adjacent Department of Oral Medicine
and Radiology, Dhulikhel
tooth. The radiographic findings were Hospital,
suggestive of periapical cyst. Dhulikhel-45210, Kavre, Nepal.
E‑mail: sushmitkoju@gmail.com
Surgical enucleation was done under local
anesthesia after obtaining an informed
consent from the patient. The operating Access this article online
site was anesthetized with 2% lignocaine Website: www.jdrr.org
containing 1:100,000 adrenaline. Sulcular
DOI: 10.4103/jdrr.jdrr_64_18
incision from the region of 13–21 was
Quick Response Code:
given. Then, a vertical incision mesial to 13
How to cite this article: Koju S, Chaurasia NK,
Marla V, Niroula D, Poudel P. Radicular cyst of the
anterior maxilla: An insight into the most common
inflammatory cyst of the jaws. J Dent Res Rev
2019;6:26-9.

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Koju, et al.: An insight into the most common cyst of jaw

and distal to 21 was given, and a trapezoidal mucoperiosteal
flap was raised. The overlying thinned bone was removed
with bur under copious irrigation to expose the cystic mass.
During the procedure, the cyst was found to be infected
with the evidence of pus discharge from the cyst. The cyst
was enucleated, and thorough curettage was done. Flap
closure was done with 3–0 silk suture, and the specimen
was sent for histopathological examination [Figure 2].
Histopathological examination revealed a cystic cavity
lined by nonkeratinized stratified squamous epithelium
arranged in an arcading pattern, interspersed with intense
inflammatory cell infiltration consisting chiefly of
lymphocytes and plasma cells. Russel’s bodies were also
noted at places. The histopathological findings confirmed
the diagnosis of radicular cyst [Figure 3].
as apical cyst. At present, it is referred to as radicular cyst/
true cyst. Sometimes, the cyst may appear on the lateral
aspect of the root when the lesion is associated with lateral
accessory root canals.[5] Among all the jaw cysts, radicular
cysts make up about 52%–68%.[4]
It involves both the primary and permanent dentition with
a range of 0.5%–3.3%. They are more common in males
compared to females with a ratio of 1.6:1. Females are
more concerned about their teeth, which might be a reason
for lower frequency of the lesion in females.[2]
The anterior maxilla is more common as compared to the
mandible. The involvement of anterior maxilla may be
due to trauma, caries, and old silicate restorations in the
anterior teeth.[6] In our case, trauma was the cause behind

Discussion
Periapical cysts are inflammatory jaw cysts that appear at
the apices of infected teeth with necrotic pulps. Based on
the opening or connection of the root canal to the epithelial-
lined cavity, periapical cyst were categorized into bay cyst
or apical cyst.[2] The cystic cavity with epithelial linings
that are open to the root canal is considered as a bay cyst,
which is now termed as “periapical pocket cysts” due to its
similarities with the marginal periodontal pocket,[2] whereas
a cystic cavity with complete epithelialization but no
opening into the apical foramen and root canal is regarded

Figure 2: Intra‑ and post‑operative procedures

a e

Figure 1: Intraoral periapical radiograph and maxillary anterior occlusal

radiograph showing the lesion

b c d

a b Figure 4: Pathogenesis of Radicular cyst (a) carious tooth showing a

Figure 3: Histopathological picture (a) nonkeratinized squamous epithelium periapical infection (b) phase of initiation (c) phase of proliferation (d) phase
with arcading pattern (×10) (b) red arrows showing Russell bodies (×100) of cyst formation (e) nonvital tooth with a radicular cyst

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Koju, et al.: An insight into the most common cyst of jaw
the development of the lesion. There are various opinions
put forward for explaining the formation of this cyst.
Torabinejad  (1983) described the pathogenesis of radicular
cyst according to the “breakdown/nutritional deficiency
theory” and “abscess cavity theory.” The “breakdown” theory
suggests that after provocation, the epithelial cells continue
to proliferate following which the central cells become
deprived of nutrition from the surrounding connective tissue
and undergo liquefactive necrosis, leading to the development
of a microscopic cyst. According to the “abscess cavity”
theory, the epithelial cells proliferate and line a preexisting
cavity  (abscess) because of their inherent tendency to cover
exposed connective tissue surfaces. This theory was also
supported by Mcconnell.[7] Another hypothesis suggested
that the cyst formation was due to a direct result of epithelial
proliferation around a space caused by proteolytic activity
occurring in the connective tissue.[2] However, the most
accepted theory is the epithelial breakdown theory as also
supported by previous articles.[2,7] The pathogenesis of
radicular cysts can be further described under three distinct
phases, namely, the phase of initiation, the phase of cyst
formation, and the phase of enlargement [Figure 4].[8]
Initially, the epithelial cell rests of Malassez in the PDL
are stimulated to proliferate as a result of trauma or
infection  [Figure  4b]. Next, a cavity is formed by the
liquefactive necrosis of odontogenic epithelium [Figure 4c].
The third phase  (enlargement) has been the focus of
considerable experimental work  [Figure  4d]. Studies in
the past have provided evidence for the hypothesis that
osmosis has a role to play toward cyst enlargement. The
lytic products of the epithelial and inflammatory cells make
a contribution to the change in osmotic pressure in different
areas, leading to increase in the size of cysts.[2] The size of
a radicular cyst on an average can range from 0.5 to 1.5 cm
in size. A  rare case reported a 5  cm  ×  3.5  cm intraosseous
radiolucent lesion diagnosed as radicular cyst.[9]
The different phase of the pathogenesis of radicular cyst
may also be described in relation to the different molecular
interactions. The phase of initiation has been linked to
the role of various cytokines and chemokines  [Figure  4b].
The infection from the caries spreads into the periapical
area, where the bacterial endotoxins trigger the epithelial
cell rests to multiply. As a result, an inflammatory process
occurs, resulting in the release of cytokines.[10,11]
The chemokines such as Regulated upon Activation,
Normal T‑cell Expressed, and Secreted, interferon
gamma‑induced protein, and monocyte chemoattractant
protein are frequently encountered in the radicular cysts
and have thought to have a role in the pathogenesis
of the cyst formation.[12] In addition, the secretion of
vascular endothelial growth factor  (an angiogenic growth
factor) has been identified, which seems to increase the
vascular permeability, leading to expansion of the cyst.[13]
Bone‑resorbing factors such as receptor activator of nuclear
28 Journal of Dental Research and Review | Volume 6 | Issue 1 | January-March 2019
factor kappa‑Β ligand and osteoprotegerins have been
expressed in radicular cyst, which could have a role in
facilitating the cystic expansion.[13] The osteoclastic bone
resorption may be increased by a wide range of biologically
active molecules.[14]
Clinically, the teeth affected with radicular cyst are
asymptomatic. Radicular cyst may present as a swelling of
the jaw and may be associated with pain/loosening of tooth.
Root resorption of the affected tooth and displacement of
the adjacent teeth have also been observed.[15]
The cystic fluid plays an important role in the diagnosis
of odontogenic cysts. The cystic content may vary from a
clear, yellow‑colored fluid to a solid cheese‑shaped lump.
Total protein content is usually between 5 and 11 g/100 ml.
This is greater in comparison to the protein contents of
other odontogenic cysts such as odontogenic keratocyst
and dentigerous cyst.[16] The concentration of globulin
(both α1 and β) has been observed to be higher than that
observed in other odontogenic cysts.[16]
Histologically, the cystic cavity is lined by nonkeratinized
stratified squamous epithelium, which may be discontinuous,
especially in areas of intense inflammatory cell infiltration.
In the early stages, cells of the epithelial lining may be
proliferative and show arcading pattern with intense chronic
inflammatory infiltrate. Rarely, mucous‑producing cells
may be observed within the epithelial lining. The presence
of these mucous cells is thought to be due to metaplastic
transformation of the squamous cells. This particular finding
was observed in the current case as well. The underlying
connective tissue wall is usually mature and collagenous and
is infiltrated by chronic inflammatory cells; predominantly
composed of lymphocytes and plasma cells. The lumen of
the cyst usually contains a fluid with varying concentration
of protein and may contain a great deal of cholesterol. In rare
instances, limited amounts of keratin may also be found.[17]
Rushton bodies  (hyaline) are observed occasionally, and
these are described as cuticular or keratin‑like products of
odontogenic epithelium. These form as a result of entrapment
of blood vessels within the epithelium, resulting in vascular
thrombosis. Another hypothesis suggests that they are
secretions of stimulated epithelial cells that later undergo
calcification.[18] It may also form due to elastotic degeneration
or as a product of cellular reaction to extravasated serum.[19]
Cholesterol crystals in paraffin sections are dissolved by the
fat solvents during tissue processing, leaving a needle‑shaped
cleft known as “cholesterol clefts” within capsular stroma.[20]
The cholesterol cleft is actually formed as a result of
degeneration and disintegration of epithelial cells, which
later get accumulated in the stroma.[21] However, another
school of thought suggests that cholesterol is derived
from the circulating plasma lipids.[20] Finally, according to
Browne RM, the main source of cholesterol crystals is the
disintegration products of hemolysis.[19]
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Koju, et al.: An insight into the most common cyst of jaw
Another feature, that is, commonly encountered in
the histopathology of radicular cysts are described as
Russell bodies. Initially, Russel bodies were thought to
be degenerated plasma cells that were persisting in the
stroma.[22] Later, Jordan and Speidel suggested that these
bodies were nothing but hemocytoblasts, which failed
to undergo normal transformation.[22] Further, Michaels
suggested that these are actually red blood corpuscles,
which had been engulfed by the plasma cells.[22]
The treatment of the radicular cyst depends on the size and
localization of the lesion.[23] It can be treated with endodontic
therapy, extraction, surgical procedure such as enucleation,
and marsupialization.[3] In our case, the treatment of
choice was surgical enucleation and curettage. One of the
complications associated with a poor prognosis of radicular
cyst is the occurrence of malignant transformation of the
lining epithelial cells. One report in the literature describes
the formation of squamous odontogenic tumor‑like
proliferations within the lining of radicular cysts.[23]
These occurrences have been observed in around 3.4% of
the cases studied. Radicular cyst of the maxillary region
was the most common site, showing such transformation.[24]
Therefore, the treatment of radicular cysts should be prompt
to avoid any potential complications.
Conclusion
Radicular cyst is one of the common lesions encountered
in dental practice. The pathogenesis of cyst formation is
a complex process involving a wide range of biologically
active molecules and their interactions. In this article, we
have tried to illustrate the pathogenesis of cyst formation
and also the various clinical and diagnostic features. Since
there are chances of neoplastic transformation within the
epithelial lining of a radicular cyst, proper treatment and a
long‑term follow‑up are recommended.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the patient has given
her consent for her images and other clinical information
to be reported in the journal. The patient understands that
name and initial will not be published and due efforts
will be made to conceal identity, but anonymity cannot be
guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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