MARSUPIALIZATION with ENUCLEATION of
MANDIBULAR LATERAL PERIODONTAL CYST
De Ocampo Elaine, Dizon Shimeree L., Feliciano Ulyssess Ellese A., Romulo, Dennison Ivan , Peredes, Heinrich James
COLLEGE OF DENTISTRY, OUR LADY OF FATIMA UNIVERSITY
Abstract
Lateral periodontal cyst (LPC) are defined as non-inflammatory
developmental cysts located adjacent or lateral to the root of a vital tooth.
The radiograph shows a well-defined, unilocular, round, or ovoid
radiolucent area. Histopathological features, showing a thin epithelial lining
with focal epithelial and stratified squamous epithelial lining only a few
cells thick. Diagnosis is mostly based on radiographs and clinical findings. A
25-year-old female patient reported asymptomatic swollen in the left
mandibular lateral incisor and canine region. Based on this case report,
unicystic Lateral periodontal cyst can be successfully managed through
marsupialization with enucleation.
Introduction
Cystic lesions are a sac-like pocket of membranous tissue that contains
fluid, air, or other substances. Cysts can grow almost anywhere in your
body or under your skin. There are many different types of cysts. Most
cysts are benign, or noncancerous. today we are focusing on maxillary cyst
and mandibular cyst these are pathologic cavities that contains liquid or
semiliquid content delimited wholly or partially by epithelium they are
odontogenic or nonodontogenic in origin. This cystic lesions can be
manage in different ways and techniques. Lateral periodontal cysts (LPCs)
are defined as non-keratinized and non-inflammatory developmental cysts
located adjacent or lateral to the root of a vital tooth. LPC are a rare form
of jaw cysts, with the same histopathological characteristics as gingival
cysts of adults. They are commonly found in the lateral periodontium or
within the bone between vital teeth most common location is in between
canines & premolars. This cystic lesion usually asymptomatic in nature and
can be diagnose using radiographic examination. It will appear well defined
round, oval or sometimes tear drop in shape with radiopaque border. In
this review, we will focus about marsupialization and enucleation of cyst as
management for patient with lateral periodontal cyst.
Case Report
A 25-year old female student came in to the clinic complaining of
swollen gums and face. Patient has no known systemic illness but maternal
side has a history of hypertension and paternal side has a history of
prostate and liver cancer. 4 months prior to consultation the patient started
feeling a sharp and throbbing pain whenever she chew or grind food. She
took Mefenamic acid 250mg every 6hours for 3 days to ease the pain but
the pain kept coming back. Extraoral examination showed asymmetrical
face of the patient and lips were deviated to the right. Intraoral
examination revealed cystic lesions on the Maxilla and Mandible of the
patient. On the third quadrant, a Periapical radiograph revealed a well-
defined, unilocular, round radiolucency between the apex of tooth #32 and
#33 [Fig.1].
Fig.1: Periapical radiograph shows a well-defined,
unilocular, round radiolucency between the apex of
tooth #32 and tooth #33 creating an expansion and
displacement of tooth #31.
Treatment plan was Marsupialization with Enucleation. Patient was
placed under Inferior Alveolar Nerve Block. Circular incision was created
between tooth #32 and #33 to form the window or opening [Fig.2].
Incisional biopsy was performed and the size of the harvested specimen
was 8cm [Fig.3]. The specimen was placed on the container with 10%
formalin and was sent to the laboratory for histopathologic examination.
Rongeur was used to remove the shearings. The cystic walls were sutured
then packed with iodoform gauze [Fig.4].
[Fig.2] [Fig.3] [Fig.4]
Fig.2: Showing the circular incision created.
Fig.3: showing the size of the specimen harvested.
Fig.4: shows the sutured cystic walls packed with iodoform gauze
The patient was given post-op instructions and prescribed
medications. The patient was dismissed and was instructed to return every
3 days starting from Oct.1, 2020 up to Oct. 25, 2020 for a total of 9
meetings for the replacement of the iodoform gauze [Fig.5].
[Fig.5] Showing the replacement of
iodoform gauze.
The patient came back for the Enucleation of the cyst. Patient was placed
under Inferior Alveolar Nerve Block. The last iodoform gauze was removed
from the circular incision. Mucogingival incision was made from the mesial
aspect of tooth #41 to the distal of tooth #34 to form a triangular flap.
Tooth #32 and #33 were extracted due to bone resorption then the
enucleation of the cyst was performed [Fig.6]. rongeur was used to remove
the shearings. Surgical site was irrigated, the triangular flap was
repositioned and sutured in place using 3-0 silk sutures utilizing simple
interrupted suturing technique. The harvested lesion was 16cm, placed on
container with 10% formalin then sent to the lab for histopathologic
examination which then confirmed the provisional diagnosis of Lateral
Periodontal Cyst.
[Fig.6] Showing the site after enucleation and
extraction.
Patient came back 1 week later for suture removal. Normal healing
was observed. The Histopath and biopsy reports were discussed. Follow up
check up for redo panoramic and periapical radiographs after 1 month.
Discussion:
Lateral periodontal cyst (LPC) is a relatively rare odontogenic
pathology, representing about 0.4% of all odontogenic cysts. It has been
reported predominantly as an incidental finding and is a harmless entity
characterized by an intraosseous, nonkeratinized, noninflammatory, and
developmental odontogenic cyst of epithelial origin. LPC is usually
symptomless and is discovered during routine radiographic examination
and occurs most frequently in the alveolar process of the mandibular
canine and premolar regions, followed by the anterior maxilla. Although it
is commonly reported between the fourth to the seventh decades of life
and most commonly on males.
In this case, based on the radiographic examination result, it shows
a well-defined, unilocular, round or ovoid radiolucent area. The cyst is
extensive and lies between the apex and the cervical margin of tooth #32
and #33 wherein it created an expansion and also displacement tooth #31.
Histopathologically, is a distinct type of developmental cyst characterized
by a thin, nonkeratinized epithelium usually 1 to 5 cell layers thick, which
resembles the reduced enamel epithelium. Treatment for this case was
marsupialization including decompression, enucleation of the cyst and the
removal of tooth # 32 &33 due to the possession of remnants of the cyst
that may damage the adjacent structures in the oral cavity.
The patient had undergone fine needle aspiration biopsy wherein
we recovered a minimum amount of yellowish colored fluid which indicates
that the lesion is malignant, followed by incision, to get a sample tissue
specimen that was immediately sent to the laboratory for histopathological
examination to confirm the nature and recurrence rate of the said lesion.
In our case, marsupialization and enucleation followed by the
removal of the said teeth was done while the patient was under local
anesthesia.
Conclusion:
Treatment modalities for cyst have evoked the greatest debates
and controversies because of the size, localization, pathological formation
and recurrence potential of cyst.
Enucleation has been the most effective and reliable method
because it completely remove the cystic capsule and reducing the possible
recurrence.
For marsupialization, it facilitates surgical treatment, promotes and
preserves normal tissues, reduces the necessity of surgical reconstruction
and cost, yet showing excellent results.