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Table of Contents   
CASE REPORT  
Year : 2018  |  Volume : 29  |  Issue : 6  |  Page : 836-839
Radicular cyst associated with primary molar: Surgical intervention and space management


1 Department of Pediatric Dentistry, Gokuldham Medical Center, Mumbai, India
2 Department of Pediatric and Preventive Dentistry, YMT, Dental College and Hospital, Navi Mumbai, Maharashtra, India
3 Department of Oral Maxillofacial Surgery, Gokuldham Medical Center, Mumbai, India

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Date of Web Publication24-Dec-2018
 

   Abstract 


Radicular cysts associated with primary teeth are rare. This case report describes radicular cyst associated with carious primary mandibular second molar in a 5-year-old patient and discusses its surgical intervention, space management, and follow-up for 3½ years.

Keywords: Enucleation, primary tooth, radicular cyst, space management

How to cite this article:
Sevekar S, Subhadra H N, Das V. Radicular cyst associated with primary molar: Surgical intervention and space management. Indian J Dent Res 2018;29:836-9

How to cite this URL:
Sevekar S, Subhadra H N, Das V. Radicular cyst associated with primary molar: Surgical intervention and space management. Indian J Dent Res [serial online] 2018 [cited 2019 Jan 21];29:836-9. Available from: http://www.ijdr.in/text.asp?2018/29/6/836/248257

   Introduction Top


Radicular cysts are known to be the most common cystic lesions of the jaws. They comprise about 52.3% of jaw cysts and 62% of cysts of odontogenic origin. They develop from cystic degeneration of cell rests of Malassez, secondary to inflammatory stimulation arising from the necrotic pulp. Surprisingly, those arising from primary teeth are considered rare. In an extensive survey of 1300 radicular cysts associated with primary and permanent dentition, the prevalence of radicular cyst arising from primary teeth was only 0.5%.[1] The low frequency is puzzling, assuming that there is no difference in the developmental mechanism of radicular cyst in primary and permanent dentition.[2]

Radicular cysts associated with primary teeth pose a diagnostic challenge as they mimic dentigerous cyst clinically, histologically and radiographically.[3] Differentiation between the two is essential to prevent unwarranted extraction of permanent successor.


   Case Report Top


A 5-year-old male patient reported with a swelling on the lower right side of the face. Swelling was present since 1 month. On extraoral examination, a diffuse, nontender, and bony hard swelling was noticed on the lower right side of the face. Intraoral examination revealed grossly destructed deciduous mandibular molar. The parent did not give any history of previous dental treatment. The panoramic radiograph showed a unilocular radiolucent lesion with smooth, well-defined borders measuring about 1.5 cm × 2 cm in relation to distal root of 85. There was considerable displacement of tooth buds of second premolar and permanent first molar [Figure 1]. Based on the clinical and radiographic findings, provisional diagnosis of radicular cyst was made with differential diagnosis of lateral dentigerous cyst arising from 45.
Figure 1: Well-defined radiolucent lesion in relation to distal root of 85 and displaced permanent tooth buds

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Extraction of 85 and cyst enucleation under general anesthesia was planned. As permanent first molar showed excessive mesial inclination, we decided to place distal shoe space maintainer to prevent it from further tipping mesially. An incision was made from left canine to the left second primary molar along the gingival margin and the site was exposed. The buccal cortical plate was considerably thin over the lesion. The grossly carious second primary molar was extracted. Piezoelectric device was used to cut buccal cortical plate. The cystic lining was enucleated. Enucleated cystic lining was preserved for histopathology examination. Distal shoe space maintainer was cemented. After the bleeding was controlled, the flap was sutured back and primary closure was achieved [Figure 2] and [Figure 3].
Figure 2: Distal shoe appliance in situ and primary closure of the surgical site

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Figure 3: Immediate postoperative radiograph

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Microscopic examination revealed a cystic lumen lined by nonkeratinized stratified squamous epithelium. The cyst was covered by fibrous connective tissue that was infiltrated by mixed inflammatory cells [Figure 4]. Orthopantomography (OPG) obtained at 6-month follow-up showed good amount of bone regeneration in the area of cystic lesion. First permanent molar and second premolar showed continued development [Figure 5].
Figure 4: Histopathologic section of cystic lining under ×100 magnification

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Figure 5: Orthopantomography at 6-month follow-up

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At 1-year follow-up, first permanent molar had erupted with favorable crown angulation [Figure 6] and [Figure 7]. Distal extension of the space maintainer was cutoff and rough edges were smoothened using rotary instrument. As contralateral permanent molar had also erupted to favor band placement, lingual arch space maintainer was fabricated and cemented to maintain space for 34 and 45. OPG at 3½-year follow-up showed complete bone regeneration in the cyst region and continued development of second premolar [Figure 8].
Figure 6: Erupted first permanent molar at 1-year follow-up

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Figure 7: Orthopantomography at 1-year follow-up

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Figure 8: Orthopantography at 3 ½ year follow-up

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   Discussion Top


Radicular cyst comprises about 52% of all the jaw cysts. However, radicular cysts arising from primary teeth are considered to be rare.[1] The reason for the low incidence of radicular cyst in primary teeth compared with permanent teeth is not clear. There is no difference in the inflammatory response to caries in both primary and permanent teeth.[4] Low incidences could be because primary teeth are present in the jaw for short period. However, this period should be sufficient for the development of cyst because primary teeth remain in the jaw for five to six years after the pulp has become nonvital.[5] According to Mass E et al. (1995).[2] prevalence is probably higher than that reported. In a survey of radiolucent lesions associated with primary molars, 73.5% were diagnosed as radicular cysts. They suggested that radicular radiolucencies related to primary teeth tend to be ignored and often resolve after the extraction of the tooth. Moreover, pulpal and radicular infections in primary teeth tend to drain through sinus tract or the marginal gingiva, thus causing less severe symptoms, which may remain untreated.[2]

Mandibular molars are the favored site for the development of radicular cyst as they are frequently affected by caries.[5],[6] Cortical bone in this region is thick; therefore, lesions may not drain readily through sinus tract.[7]

In case of permanent teeth, maxillary anterior region is the most common site for radicular cyst, because of high frequency of trauma and dens in dente in anterior teeth.[1] In case of primary teeth, failed pulp therapy is considered the major contributing factor for the development of radicular cyst. Several authors have reported radicular cyst associated with primary teeth, following pulp therapy.[6],[7],[8],[9],[10],[11],[12] A review of the literature shows the total cases reported from 1927 to 2014, to be 112 and attributes 56% of them to be in response to pulp therapy.[4] Some of these cysts showed rapid growth, large size, and cortical plate expansion.[5],[6],[7] In case series presented by Grundy GE et al. (1984), radicular cysts were presented at an average of 20 months after pulp therapy with formocresol, KRI paste, or caustinerf.[7] It has been hypothesized that pulp therapeutic agents such as formocresol along with tissue protein may induce antigenic stimulation of periradicular tissue resulting in rapid growth and cortical plate expansion.[9] However, our patient had not undergone any previous dental treatment and presented with large radiolucent lesion.

Highest incidence of radicular cyst arising from primary teeth are seen in 7–8-year olds.[4] Growth rate of radicular cyst associated with primary teeth is reported to be 4-mm annually. Considering the age of our patient and size of the lesion, we suspect rapid growth of the cyst in the current case.

Radicular cyst associated with primary molar can be mistaken for dentigerous cyst arising from permanent successor.[3] Differential diagnosis is vital to avoid extraction of permanent successor. Comprehensive assessment of clinical, radiographic, and histopathology examination and surgical findings can aid in this process. The clinical and radiographic signs that help in differentiation between the two have been enumerated by Wood RE et al. (1988).[3] The following features can help in confirming the diagnosis of radicular cyst.

  • There should be evidence of carious/traumatized/endodontically treated tooth
  • Loss of lamina dura around the roots of the suspected tooth
  • Follicular space around the permanent successor is intact and clearly visible.


In case of radicular cyst, complete enucleation of the cyst and preservation of permanent successor is a suitable treatment option.[8] Children have high propensity for bone regeneration. Faster healing of the postsurgical osseous defects can be expected.[13]

Marsupialization of the cystic lesion and using an appliance with projection for decompressing the lesion is another treatment option. However, the postoperative care is more demanding. Patient and parent cooperation are needed for success.[8] In adults, following marsupialization, the time required for radicular cyst to reduce to their half size is approximately 6 months (Kubota Y et al. 2013).[14] Although healing in children can be expected faster, still considerable time will be required.

Spontaneous alignments of the permanent teeth are likely even if their initial positions are not favorable.[8] The present case showed good amount of bone regeneration and considerable alignment of displaced permanent teeth at 6-month follow-up. Distal shoe space maintainer with intra-alveolar extension aided in preventing first permanent molar from further tipping mesially and helped in achieving satisfactory crown angulation.


   Conclusion Top


Clinician should always consider the possibility of radicular cyst arising from carious primary teeth. Radiographic follow-up of endodontically treated primary teeth at regular interval is crucial for early discovery of radicular cyst. Early diagnosis is important to avert adverse effect to the underlying permanent teeth.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Shear M, Speight PM. Radicular cyst and residual cyst. In: Cyst of the Oral Maxillofacial Region. 4th ed. Oxford: Blackwell Publishing ltd.; 2009. p. 123-42.  Back to cited text no. 1
    
2.
Mass E, Kaplan I, Hirshberg A. A clinical and histopathological study of radicular cysts associated with primary molars. J Oral Pathol Med 1995;24:458-61.  Back to cited text no. 2
    
3.
Wood RE, Nortjé CJ, Padayachee A, Grotepass F. Radicular cysts of primary teeth mimicking premolar dentigerous cysts: Report of three cases. ASDC J Dent Child 1988;55:288-90.  Back to cited text no. 3
    
4.
Nagata T, Nomura J, Matsumura Y, Yanase S, Fujii T, Oka T, et al. Radicular cyst in a deciduous tooth: A case report and literature review. J Dent Child (Chic) 2008;75:80-4.  Back to cited text no. 4
    
5.
Takiguchi M, Fujiwara T, Sobue S, Ooshima T. Radicular cyst associated with a primary molar following pulp therapy: A case report. Int J Paediatr Dent 2001;11:452-5.  Back to cited text no. 5
    
6.
Lustig JP, Schwartz-Arad D, Shapira A. Odontogenic cysts related to pulpotomized deciduous molars: Clinical features and treatment outcome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:499-503.  Back to cited text no. 6
    
7.
Grundy GE, Adkins KF, Savage NW. Cysts associated with deciduous molars following pulp therapy. Aust Dent J 1984;29:249-56.  Back to cited text no. 7
    
8.
Chiu WK, Sham AS, Hung JN. Spontaneous alignment of permanent successors after enucleation of odontogenic cysts associated with primary teeth. Br J Oral Maxillofac Surg 2008;46:42-5.  Back to cited text no. 8
    
9.
Savage NW, Adkins KF, Weir AV, Grundy GE. An histological study of cystic lesions following pulp therapy in deciduous molars. J Oral Pathol 1986;15:209-12.  Back to cited text no. 9
    
10.
Sandhyarani B, Noorani H, Shivaprakash PK, Dayanand AH. Fate of pulpectomized deciduous teeth: Bilateral odontogenic cyst? Contemp Clin Dent 2016;7:243-5.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Nagarathna C, Jaya AR, Jaiganesh I. Radicular cyst followed by incomplete pulp therapy in primary molar: A case report. J Indian Soc Pedod Prev Dent 2013;31:191-3.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Lamba G, Ravi GR. Replantation of displaced underlying successor and marsupialization of radicular cyst associated with a primary molar. Int J Clin Pediatr Dent 2015;8:70-4.  Back to cited text no. 12
    
13.
Ramakrishna Y, Verma D. Radicular cyst associated with a deciduous molar: A case report with unusual clinical presentation. J Indian Soc Pedod Prev Dent 2006;24:158-60.  Back to cited text no. 13
[PUBMED]  [Full text]  
14.
Kubota Y, Imajo I, Itanoga R, Takenoshita Y. Effects of the patient's age and the size of the primary lesion on the speed of shrinkage after marsupialisation of keratocystic odontogenic tumours, dentigerous cysts, and radicular cysts. Br J Oral Maxillofac Surg 2013;51:358-62.  Back to cited text no. 14
    

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Correspondence Address:
Dr. Shrirang Sevekar
Gokuldham Medical Centere, Sai Road, Gokuldham, Gen A K Vaidya Marg, Goregaon East, Mumbai - 400 063, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_785_16

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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    Abstract
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