|Year : 2014 | Volume
| Issue : 3 | Page : 145-148
Management of a large radicular cyst: A non-surgical endodontic approach
Shweta Dwivedi1, Chandra Dhar Dwivedi2, Thakur Prasad Chaturvedi3, Harakh Chandra Baranwal1
1 Department of Conservative Dentistry and Endodontics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Oral and Maxillofacial Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
3 Department of Orthodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
|Date of Web Publication||6-Aug-2014|
Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
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.
Keywords: Calcium hydroxide, non-surgical endodontic therapy, periapical lesion, radicular cyst, vitapex
|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
|How to cite this URL:|
Dwivedi S, Dwivedi CD, Chaturvedi TP, Baranwal HC. Management of a large radicular cyst: A non-surgical endodontic approach. Saudi Endod J [serial online] 2014 [cited 2021 May 6];4:145-8. Available from: https://www.saudiendodj.com/text.asp?2014/4/3/145/138149
| Introduction|| |
Radicular 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. 
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 be, the treatment option should be kept as conservative as possible. 
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.  Its mechanism of actions , is achieved through the ionic dissociation of Ca(2+) and OH(-) ions and their effect on vital tissues, the induction of hard-tissue deposition  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.
| Case report|| |
A 24-year-old female patient reported to the Department of Oral and Maxillofacial 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 1]a].
|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)|
Click here to view
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 1]b] 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 1]c]. 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 palate [Figure 2]a and b] which was slightly pale straw colored and it was sent for microscopic examination. The laboratory result was a periapical cyst.
|Figure 2: Photograph the palatal selling during aspiration of the lesion (a) and after (b)|
Click here to view
Canals were cleaned and shaped by Protaper files (Dentsply Inc, Maillefer, Dentsply India) using a crown down technique. Irrigation was done using normal 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 3]a]. 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 3]b].
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 4]a]. After 3 months, palpable portion of palate become hardened. At 3 months [Figure 4]b] 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 4]c] 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 4]d].
|Figure 3: Periapical radiograph after vitapex extrusion within the lesion (a). Occlusal view of the palate after 1 month of commencement of treatment (b)|
Click here to view
|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)|
Click here to view
| 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 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.  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). ,
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. 
As the pocket cyst is in communication with the root canal, healing should occur in most cases following through non-surgical root canal treatment.  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 periapical lesions. , A high percentage of 94.4% of complete and partial healing of small periapical lesions following nonsurgical endodontic therapy has also been reported.  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. 
Calcium hydroxide, historically, is widely used as an intracanal endodontic material, due to its high alkalinity,  tissue dissolving effect, causes induction of repair by hard tissue formation and has bactericidal effect , but will remain in the tissue for considerable time  and therefore cannot be considered biocompatible.  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,  a few reports dealt with the negative side effects of Ca(OH) 2 including bone necrosis and continuing inflammatory response in repaired mechanical perforations, , 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.  Also, some authors reported deleterious effects if the material is extruded under a high pressure during endodontic treatment. ,
However, few studies reported that placement of intracanal Ca(OH) 2 would have a direct effect on periapical inflamed tissue by diffusion of hydroxyl ions (OH-) through the dentinal tubules, and in this manner would favor periapical healing and encourage osseous repair.  In areas of root resorption, it also inhibits osteoclastic activity.  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.  Calcium hydroxide has been found to be resorbed extraradicularly without apparent ill effect and proved to be clinically and radiographically successful. ,
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.
| References|| |
|1.||Narula H, Ahuja B, Yeluri R, Baliga S, Munshi AK. Conservative non-surgical management of an infected radicular cyst. Contemp Clin Dent 2011;2:368-71. |
|2.||Balaji Tandri S. Management of infected radicular cyst by surgical decompression. J Conserv Dent 2010;13:159-61. |
|3.||Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod 1990;16:498-504. |
|4.||Malagnino VA, Amori P, Gambarini G, De Marco M. Recent findings in the mechanism of action of calcium hydroxide in apexification. G Stomatol Ortognatodonzia 1989;8:14-7. |
|5.||Siqueira JF Jr, Lopes HP. Mechanisms of antimicroial activity of calcium hydroxide: A critical review. Int Endod J 1999;32:361-9. |
|6.||Al Ansary MA, Day PF, Duggal MS, Brunton PA. Interventions for treating traumatized necrotic immature permanent anterior teeth: Inducing a calcific barrier and root strengthening. Dent Traumatol 2009;25:367-79. |
|7.||Natkin E, Oswald RJ, Carnes LI. The relationship of lesion size to diagnosis, incidence, and treatment of periapical cysts and granulomas. Oral Surg Oral Med Oral Pathol 1984;57:82-94. |
|8.||Nair PN. New perspectives on radicular cysts: Do they heal? Int Endod J 1998;31:155-60. |
|9.||Rhodes JS. Advanced Endodontics Clinical Retreatment and Surgery; Rationale for endodontic retreatment. 1 st ed. London, UK: Taylor and Francis Group; 2006. p. 13. |
|10.||Valois CR, Costa-Júnior ED. Periapical cyst repair after nonsurgical endodontic therapy-case report. Braz Dent J 2005;16:254-8. |
|11.||Ramachandran Nair PN, Pajarola G, Schroeder HE. Types and incidence of human periapical lesions obtained with extracted teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:93-102. |
|12.||Caliºkan MK, Sen BH. Endodontic treatment of teeth with apical periodontitis using calcium hydroxide: A long-term study. Endod Dent Traumatol 1996;12:215-21. |
|13.||Murphy WK, Kaugars GE, Collet WK, Dodds RN. Healing of periapical radiolucencies after nonsurgical endodontic therapy. Oral Surg Oral Med Oral Pathol 1991;71:620-4. |
|14.||Tronstad L, Andreasen JO, Hasselgren G, Kristerson L, Riis I. pH changes in dental tissues after root canal filling with calcium hydroxide. J Endod 1981;7:17-21. |
|15.||Sjögren U, Figdor S, Spångberg L, Sundqvist G. The antimicrobial effect of calcium hydroxide as a short-term intracanal dressing. Int Endod J 1991;24:119-25. |
|16.||Ahlgren FK, Johannessen AC, Hellem S. Displaced calcium hydroxide paste causing inferior alveolar nerve paraesthesia: Report of a case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:734-7. |
|17.||Sharma S, Hackett R, Webb R, Macpherson D, Wilson A. Severe tissue necrosis following intra-arterial injection of endodontic calcium hydroxide: A case series. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:666-9. |
|18.||Lindgren P, Eriksson KF, Ringberg A. Severe facial ischemia after endodontic treatment. J Oral Maxillofac Surg 2002;60:576-9. |
|19.||Nelson Filho P, Silva LA, Leonardo MR, Utrilla LS, Figueiredo F. Connective tissue responses to calcium hydroxide-based root canal medicaments. Int Endod J 1999;32:303-11. |
|20.||Shimizu T, Kawakami T, Ochiai T, Kurihara S, Hasegawa H. Histopathological evaluation of subcutaneous tissue reaction in mice to a calcium hydroxide paste developed for root canal fillings. J Int Med Res 2004;32:416-21. |
|21.||De Bruyne MA, De Moor RJ, Raes FM. Necrosis of the gingiva caused by calcium hydroxide: A case report. Int Endod J 2000;33:67-71. |
|22.||Orucoglu H, Cobankara FK. Effect of unintentionally extruded calcium hydroxide paste including barium sulfate as a radiopaquing agent in treatment of teeth with periapical lesions: Report of a case. J Endod 2008;34:888-91. |
|23.||Nurko C, Garcia-Godoy F. Evaluation of a calcium hydroxide/iodoform past (Vitapex) in root canal therapy for primary teeth. J Clin Pediatr Dent 1999;23:289-94. |
|24.||Kawakami T, Nakamura C, Eda S. Effects of the penetration of a root canal filling material into the mandibular canal. 1. Tissue reaction to the material. Endod Dent Traumatol 1991;7:36-41. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]