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Management of a large radicular cyst:

A non‑surgical endodontic approach
Case Report

Shweta Dwivedi, Chandra Dhar Dwivedi1, Thakur Prasad Chaturvedi2, Harakh

Chandra  Baranwal
Departments of Conservative Dentistry and Endodontics, 1Oral and Maxillofacial Surgery, 2Department of
 

Orthodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi,
Uttar Pradesh, India

Key words:
Calcium hydroxide, non‑surgical
endodontic therapy, periapical lesion,
radicular cyst, vitapex
Address for correspondence:
Dr. Shweta Dwivedi,
Department of Conservative Dentistry and
Endodontics, Faculty of Dental
Sciences, Institute of Medical Sciences,
Banaras Hindu University,
Varanasi ‑ 221 005, Uttar Pradesh, India.
E‑mail: shwetaCdwivedi@gmail.com
ABSTRACT
A radicular cyst 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 the tooth.
A radicular cyst is usually sterile unless it is secondarily infected. This paper
presents a case report of conservative non‑surgical management of a
radicular cyst associated with permanent maxillary right central incisor, right
lateral incisor and right canine in a 24‑year‑old female patient. Root canal
treatment was done together with cystic aspiration of the lesion. The lesion
was periodically followed up and significant bone formation was seen at the
periapical region of affected teeth and at the palate at about 9 months. Thus,
nonsurgical healing of a large radicular cyst with palatal swelling provided
favorable clinical and radiographic response.

INTRODUCTION be, the treatment option should be kept as

conservative as possible.[2]

R adicular cysts are the most common

odontogenic cystic lesions of inflammatory
origin affecting the jaws. They are commonly found
at the apices of the involved teeth; however, they
may also be found on the lateral aspects of the
roots in relation to lateral accessory root canals.[1]
Many radicular cysts are symptomless and are
discovered when periapical radiographs are taken
of teeth with non‑vital pulps. Over the years,
the cyst may regress, remain static or grow in
size. The treatment of the cysts can be either
nonsurgical management or surgical management
being either marsupialization or enucleation.
Nevertheless, no matter what choice it might
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The basic premise of any non‑surgical endodontic
treatment is to have a conventional orthograde
approach. In view of that calcium hydroxide
[Ca(OH)2] definitely has an edgeover, when we look
at its outstanding action as an intracanal medicament.
However, it is not a panacea.[3] Its mechanism of
actions[4,5] is achieved through the ionic dissociation
of Ca(2+) and OH(–) ions and their effect on vital
tissues, the induction of hard‑tissue deposition[6] and
the antibacterial properties.
This case report evaluates the effect of calcium
hydroxide in large cystic area. A successful conservative
non‑surgical management of a radicular cyst associated
with permanent maxillary right central and lateral
incisor and right canine in a 24‑year‑old female patient.

www.saudiendodj.com
CASE REPORT
DOI:

10.4103/1658-5984.138149
A 24‑year‑old female patient reported to
the Department of Oral and Maxillofacial

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Dwivedi, et al.: Use of calcium hydroxide in periapical area to treat large radicular cyst
Surgery (OMFS), with a complaint of palatal swelling
since last 3 years and mobility in upper right front
teeth since 2 months. Past history revealed trauma to
maxillary anterior teeth 10 years back and had a small
swelling on the anterior palate 3 years ago, which
was progressively increasing in size till the present
condition [Figure 1a].
Clinical, subjective and objective examination revealed
that the maxillary right central incisor (#11), right lateral
incisor (#12) and right canine (#13) teeth were found to
be non‑vital (necrotic) with grade II mobility. An occlusal
view of the palate revealed well‑defined radiolucency
of considerable size, [Figure 1b] involving anterior part
of the palate in relation to 11, 12 and 13, with a thin
radiopaque border. An intraoral periapical radiograph
shows laterally displaced roots of lateral incisor and
canine [Figure 1c]. The clinical and radiographic signs
were suggestive of chronic periapical abscess (cyst) in
relation to 11, 12 and 13. Hence, surgical treatment was
planned and the patient was referred to Department of
Conservative Dentistry and Endodontics to perform
access opening of 11, 12 and 13.
Access opening in the above aforesaid teeth was done
and the patient was referred to OMFS for further
treatment. But the patient was very apprehensive and
not willing for surgical intervention. Therefore, the
treatment plan was changed to provide conservative
management of the pathology on patient’s request.
Cystic fluid was first aspirated with 22 guage
needle from dependent part of the swelling on the
b c
Figure 1: Clinical photo of the palate showing a large swelling (a).
Preoperative occlusal radiographic of the radiolucent area around the
apices of teeth # 11. 12 and 13 (b). Intraoral periapical radiograph shows
laterally displaced roots of lateral incisor and canine. (c)
146
palate [Figure 2a and b] which was slightly pale straw
colored and it was sent for microscopic examination.
The laboratory result was a periapical cyst.
Canals were cleaned and shaped by Protaper
files (Dentsply Inc, Maillefer, Dentsply India)
using a crown down technique. Irrigation was
done using nor mal saline 0.9% and 5% sodium
hypochlorite (Dentpro, Amrit Chemical and Mineral
Agency, Mohali, India). Interim dressing given and the
patient was recalled the next day. On the next visit,
calcium hydroxide [Ca(OH) 2] with iodoform paste
was injected up to the cystic lesion through the root
canal by vitapex syringes [Figure 3a]. Access cavity
was sealed with interim dressing. The patient was kept
on follow up. The intracanal Ca(OH)2 dressing was
replenished after 15 days interval. After 1 month of
commencement of treatment, teeth 11, 12 and 13 were
obturated [Figure 3b].
After 1 month, a significant reduction in the size of
palatal lesion was clinically observed and after 45 days,
the palate became normal in appearance [Figure 4a].
After 3 months, palpable portion of palate become
hardened. At 3 months [Figure 4b] the radiolucency
of the lesion started disappearing but larger amount
of medicament was still remaining within the
lesion. However, at 6‑month follow up the occlusal
radiograph [Figure 4c] showed partial radiopacity with
some medicament apparent in the lesion. Complete
radiopacity was apparent in the occlusal radiograph at
the cystic area of the palate at 9‑month of follow up
[Figure 4d].
DISCUSSION
The development of a periapical cyst is a gradual
process. The inflammatory process stimulates the
epithelial rest cells of Malassez, and cystic fluid
develops around the apex which is composed of
a b
Figure 2: Photograph the palatal selling during aspiration of the lesion
(a) and after (b)
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Dwivedi, et al.: Use of calcium hydroxide in periapical area to treat large radicular cyst
a b
Figure 3: Periapical radiograph after vitapex extrusion within the
lesion (a). Occlusal view of the palate after 1 month of commencement
of treatment (b)
cholesterol. The cyst may grow by expansion from
the fluid, or it may become infected. In either case
it is pathologic. Natkin et al. postulated that the
larger the lesion, the more apt it is to be a cyst. [7]
Lateral displacement of root with tooth mobility is
pathognomonic of cysts. Cysts constitute about 15%
of all periapical lesions and nearly half of all periapical
lesions are radicular cysts. Equally significant was
the discovery in 1980 and recent confirmation that
radicular cysts exist in two structurally distinct classes,
namely those containing cavities completely enclosed
in epithelial lining (periapical true cysts) and those
containing epithelium‑lined cavities that are open to the
root canals (periapical pocket cysts).[8,9]
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 for a smaller one. However, in large lesions,
the endodontic treatment alone is not efficient
and it should be associated with decompression or
marsupialization or even enucleation of the cyst.[10]
As the pocket cyst is in communication with the root
canal, healing should occur in most cases following
through non‑surgical root canal treatment.[11] However,
a true cyst is self‑sustaining and therefore unlikely to
respond to the treatment. In these cases, a surgical
approach would be required. It is imperative to note
that when considering treatment of such a case,
conventional disinfection of the root canal is normally
indicated as an initial approach prior to surgery.
Various studies have reported a success rate of up
to 85% after endodontic treatment of teeth with
Saudi Endodontic Journal • Sep-Dec 2014 • Vol 4 • Issue 3
a b
c d
Figure 4: Clinical photograph of the palate after 1½ month of
commencement of treatment (a). Occlusal view of the palate after 3
month (b), 6 month (c) and 9 month of commencement of treatment (d)
periapical lesions.[3,12] A high percentage of 94.4% of
complete and partial healing of small periapical lesions
following nonsurgical endodontic therapy has also
been reported.[13] Large periapical lesions have been
routinely treated surgically however a more conservative
non‑surgical approach that can be treated by calcium
hydroxide can’t be overlooked.[13]
Calcium hydroxide, historically, is widely used as
an intracanal endodontic material, due to its high
alkalinity,[14] tissue dissolving effect, causes induction
of repair by hard tissue for mation and has
bactericidal effect [15,16] but will remain in the tissue
for considerable time [17] and therefore cannot be
considered biocompatible.[18] Its antibacterial actions is
due to its effect on bacterial cytoplasmic membranes,
protein denaturation, damage to DNA, carbon
dioxide absorption, action on lipopolysaccharides and
hygroscopic action.
Although it has been considered as a safe agent,[19]
a few reports dealt with the negative side effects
of Ca(OH)2 including bone necrosis and continuing
inflammatory response in repaired mechanical
perforations,[5,20] the neurotoxic effect, cytotoxicity on
cell cultures, damaged epithelium with or without a
cellular atypia when applied on hamster cheek pouches
and cellular damage following early Ca(OH)2 dressing of
avulsed teeth.[21] Also, some authors reported deleterious
effects if the material is extruded under a high pressure
during endodontic treatment.[19,21]
However, few studies reported that placement of
intracanal Ca(OH)2 would have a direct effect on periapical
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Dwivedi, et al.: Use of calcium hydroxide in periapical area to treat large radicular cyst
inflamed tissue by diffusion of hydroxyl ions (OH–)
through the dentinal tubules, and in this manner would
favor periapical healing and encourage osseous repair.[15]
In areas of root resorption, it also inhibits osteoclastic
activity.[15] Besides, a previous study also reported that
unintentionally extruded Ca(OH)2 paste into the periapical
lesion had no detrimental effect but healing might take
longer. [22] Calcium hydroxide has been found to be
resorbed extraradicularly without apparent ill effect and
proved to be clinically and radiographically successful.[23,24]
In the present study, Ca(OH)2 was used extraradicularly
in the paste form on the basis of previous study on
resorption of Ca(OH)2 beyond apex and healing with
a significant bone formation was observed at the
periapical region on regular follow‑up visits.
CONCLUSION
Surgical treatment is indicated only when nonsurgical
treatment or retreatment is impractical or unlikely to
provide the desired outcome.
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How to cite this article: Dwivedi S, Dwivedi CD, Chaturvedi TP,
Baranwal HC. Management of a large radicular cyst: A non-surgical
endodontic approach. Saudi Endod J 2014;4:145-8.
Source of Support: Nil. Conflict of Interest: None declared.
Saudi Endodontic Journal • Sep-Dec 2014 • Vol 4 • Issue 3