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 Table of Contents  
Year : 2021  |  Volume : 7  |  Issue : 3  |  Page : 176-180

An ambiguous periapical cyst: A case report and literature review

1 Department of Periodontology and Oral Implantology, Bharati Vidyapeeth Deemed to be University, Dental College and Hospital, Pune, Maharashtra, India
2 Department of Oral and Maxillofacial Surgery, Bharati Vidyapeeth Deemed to be University, Dental College and Hospital, Pune, Maharashtra, India
3 Department of Periodontology, Bharati Vidyapeeth Deemed to be University, Dental College and Hospital, Pune, Maharashtra, India

Date of Submission23-Mar-2021
Date of Acceptance07-May-2021
Date of Web Publication28-Sep-2021

Correspondence Address:
Dr. Rinisha Sinha
Department of Periodontology and Oral Implantology, Dental College and Hospital, Bharati Vidyapeeth Deemed to be University, Pune - 411 043, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAM.IJAM_40_21

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Periapical cyst or radicular cyst is the most common inflammatory odontogenic cyst of the jaws, but its association with the over-retained deciduous teeth is unusual. This case reports a 24-year-old male patient who complained of swelling in the upper right back tooth region of the mouth. It was tentatively diagnosed as an odontogenic keratocyst because of its radiographic appearance. However, after histopathological examination, it was identified as an infected periapical cyst whose etiology was an over-retained deciduous root piece. We have reported this case due to its uniqueness in terms of etiology, clinical and radiographic findings, and management. The literature review is discussed in comparison with the current case's findings as well as the indications for guided bone regeneration after a follow-up of 6 months. This article highlights that the art of clinical diagnosis lies in the ability to perform a thorough examination, followed by proper investigations that may defy the provisional diagnosis. Sometimes, it lies as a disguise and only a detailed thorough investigation can reveal its true identity.
The following core competencies are addressed in this article: Practice-based learning and improvement, Medical knowledge, Patient care.

Keywords: Case report, enucleation, extraction, guided bone regeneration, radicular cyst

How to cite this article:
Sinha R, Pranave P, Waghmare P. An ambiguous periapical cyst: A case report and literature review. Int J Acad Med 2021;7:176-80

How to cite this URL:
Sinha R, Pranave P, Waghmare P. An ambiguous periapical cyst: A case report and literature review. Int J Acad Med [serial online] 2021 [cited 2021 Nov 30];7:176-80. Available from: https://www.ijam-web.org/text.asp?2021/7/3/176/326817

  Introduction Top

The most commonly occurring chronic swellings of the jaws are cysts. The word “cyst” is derived from the Greek word “kystis” meaning “sac or bladder.”[1] A cyst is defined as a pathological cavity having fluid, semi-fluid, or gaseous contents, which are not created by the accumulation of pus.[2] Among the various types of odontogenic cysts observed, the periapical cyst is one of the most common, which is a subtype of an inflammatory cyst.[3] It is originated from the epithelium and is clinically asymptomatic but can result in a slow-growth tumefaction in the affected region. It radiographically appears as a round or oval, well-circumscribed radiolucent image involving the apex of the infected tooth.[4]

In this article, an infected periapical cyst is reported that was in association with an over-retained deciduous tooth, having peculiar characteristics and destructive nature. Its successful uneventful management was achieved with an aggressive treatment plan which could have been avoided if it was diagnosed early.

  Case Report Top

A 24-year-old male [Figure 1] presented to the department of periodontology and oral implantology for a significant swelling in the upper right back tooth region of the mouth for 1 week which aggressively increased to the present size. His past medical history was noncontributory. The patient was moderately built, nourished, and well oriented.
Figure 1: Preoperative extraoral photograph

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On extraoral examination, there was a mild-to-moderate swelling on the right side of maxilla with the skin appearing to be normal. On palpation, the swelling appeared hard, afebrile and mildly tender. Lymph nodes were nonpalpable. Intraoral examination revealed diffuse swelling, measuring 3 cm ×2 cm approximately, extending from the distal of 13 (Fédération Dentaire Internationale notation) to mesial of 17 on the upper buccal mucosa [Figure 2].
Figure 2: (a) Intraoral image showing swelling in the right maxillary region. (b) Intraoral image showing no apparent swelling on the palatal aspect

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The buccal vestibule was annihilated by the swelling with no discharge. All the involved teeth were vital and nontender to percussion. Grade I gingival enlargement was observed for 14 and Grade II gingival enlargement was seen with 15, 16, and 17. The patient's oral hygiene was fair.

The patient was advised for panoramic radiograph and cone-beam computed tomography reports for radiological evaluation [Figure 3]a, [Figure 3]b, [Figure 3]c. The radiological examination revealed a single, large, well-defined, completely radiolucent lesion in the right side of the maxilla, associated with periapical region of the teeth 13, 14, 15, 16, and 17 and an over-retained root piece of deciduous tooth 55 [Figure 4]. There was thinning and expansion of the buccal and palatal cortical plates, along with elevation and perforation of the floor of the maxillary sinus. Displacement of the root of 15 in buccal direction was also noted.
Figure 3: (a and b) Cone-beam computed tomography – reconstructed panoramic and three-dimensional. (c) Cone-beam computed tomography – cross-sectional images of 15, 16, and 17

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Figure 4: Cone-beam computed tomography showing root stump of 55 (yellow arrow)

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Routine laboratory investigations were under normal limits. Fine-needle aspiration cytology [Figure 5] revealed cheesy, turbid blood-colored fluid, consisting of sheets of neutrophils admixed with few macrophages. The cytological picture was suggestive of an acute inflammatory lesion.
Figure 5: Fine-needle aspiration cytology specimen

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Before rendering the reports, given their clinical characteristics, the differential diagnosis of odontogenic keratocyst was made. Based on the cytological analysis, we concluded it to be an infected periapical cyst whose etiology was attributed to the over-retained root piece of 55. Surgical enucleation of the cyst [Figure 6]a and [Figure 6]b combined with extraction of 14, 15, 16, and 55 under local anesthesia was planned and performed for the patient [Figure 7], and biopsy samples were collected. Intact bone was present all around the adjacent teeth. Closure of surgical site was done with 3-0 silk sutures [Figure 8]. Necessary prescriptions and postoperative instructions were given.
Figure 6: (a) Surgical enucleation. (b) Bone defect after enucleation

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Figure 7: Extracted 15, 16, 17

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Figure 8: Postsuturing

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The histopathological picture showed cystic epithelial lining and fibrocellular connective tissue stroma. The epithelium had cuboidal to low columnar hyperchromatic basal cells. The underlying connective tissue was infiltrated with diffuse, dense chronic inflammatory cells, predominantly lymphocytes, and plasma cells. Increased vascularity was seen with endothelial cell proliferation. Numerous multinucleated giant cells were also seen along with few hemorrhagic areas. Histological features confirmed the clinical diagnosis of an infected periapical cyst.

Postsurgical follow-up after 15 days showed considerable reduction in the size of swelling with prompt healing of the surgical site. At 2-month follow-up, no recurrence was observed [Figure 9]. The patient's every month follow-up is being carried on.
Figure 9: Follow-up picture (2 months postoperative)

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  Discussion Top

Radicular cysts originating from the retained root of primary teeth are very rare, and only a few cases are presented of the same.[5] They originate from the epithelial remnants of periodontal ligament (epithelial cell rests of Malassez) following pulp necrosis.[6] They are diagnosed either during a routine radiographic examination or following their acute exacerbation.[7] The prevalence of the periapical cysts in the maxilla is 60% as compared with the mandible.[4] The present case was associated with a huge buccal swelling, slightly evident extraorally and intraorally involving 15, 16, and 17 and deciduous tooth 55 which is clinically not visible.

Periapical cysts grow slowly and lead to mobility, root resorption, and displacement of the teeth. Once infected, they may lead to pain and swelling and patients become aware of the problem.[8] In our case, no mobility and/or root resorption was seen despite the presence of a large chronic infected cystic lesion. However, the root of tooth 15 showed displacement in the buccal direction.

In the present scenario, the buccal and palatal cortical plates thinned out with springiness and eggshell crackling, leading to expansion. Despite being infected, it appeared as a round unilocular radiolucency with a partially well-defined border associated with the retained root stump of a deciduous molar. The chronic periapical cyst may result in the resorption of offending tooth roots.[9] Radicular cysts arising from deciduous teeth may mimic dentigerous cyst radiographically, especially when they are multilocular.[10] In our case, the histopathological findings revealed that the cyst is lined completely by stratified squamous epithelium, along with acute and chronic inflammatory infiltrate without any Rushton bodies.

The recommended treatment option for periapical cyst is the conventional endodontic approach along with decompression[11] or surgical enucleation of a cyst with the extraction of the offending tooth. Some of the authors are in view that suspected radicular cysts must be enucleated surgically to remove all epithelial remnants.[12] However, in large lesions, the endodontic treatment alone is not efficient and should be associated with decompression or marsupialization.[13] The major disadvantage of the marsupialization technique is that the pathologic tissue is left in situ without thorough histologic examination[14] which can lead to a residual cyst. Lesions that fail to resolve with endodontic therapy may be successfully managed by extraction of the associated nonvital teeth and curettage of the epithelium in the apical zone.[15] As the present case represented a giant infected true cyst, surgical enucleation along with the extraction of offending teeth resulted in its successful management.[16]

Guided bone generation methods are used for the reparation process after surgical enucleation. From a futuristic point of view, guided bone regeneration is indicated in the current scenario after a follow-up of 6 months which will be done in another 4 months.[17] Few studies believe that regenerative techniques are not superior, either about the speed or quality of healing.[18] In contrast, other studies[17],[19] stated that conventional treatment results were less predictable when compared to regeneration methods.

We have highlighted and compared the literature with the clinical findings in our case and successfully managed to treat the patient with uneventful healing. Sometimes, entities are in a disguise and only a detailed thorough investigation can reveal their true identity. Therefore, more awareness campaigns are recommended to educate the population about the requirement for early presentation of the pathologies,[20] and early diagnosis will result in less invasive management.

Patient perspective

The patient is satisfied with the treatment received and there is no recurrence of the entity noticed even after 2 months.

Informed consent

We certify that we have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name 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


Conflicts of interest

There are no conflicts of interest.

Ethical conduct of research

We declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network (in this case, CARE guideline). The authors also attest that this clinical investigation was not determined to require Institutional Review Board/Ethics Committee review, and the corresponding protocol/approval number is not applicable.

  References Top

Nair PN. Non-microbial etiology: Periapical cysts sustain post-treatment apical periodontitis. Endod Top 2003;6:96-113.  Back to cited text no. 1
Shear M, Speight PM. Cysts of the Oral and Maxillofacial Region. 4th ed., Ch. 1. Oxford: Blackwell Munksgaard; 2007.  Back to cited text no. 2
Koseoglu BG, Atalay B, Erdem MA. Odontogenic cysts: A clinical study of 90 cases. J Oral Sci 2004;46:253-7.  Back to cited text no. 3
Shear M. Cistos da Região Bucomaxilofacial. 3rd ed. São Paulo: Editora Santos; 1999.  Back to cited text no. 4
Uloopi KS, Shivaji RU, Vinay C, Pavitra</AQ15>, Shrutha SP, Chandrasekhar R. Conservative management of large radicular cysts associated with non-vital primary teeth: A case series and literature review. J Indian Soc Pedod Prev Dent 2015;33:53-6.  Back to cited text no. 5
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Irfan M, Alauddin M, Roselinda A, Rahman SA. Big radicular cyst in a 12 year old girl: a case report. Int Med J. 2007;6 (5).  Back to cited text no. 8
Pekiner FN, Borahan O, Ugurlu F, Horasan S, Sener BC, Olgaç V. Clinical and radiological features of a large radicular cyst involving the entire maxillary sinus. Clinical and Experimental Health Sciences. 2012;2 (1):31.  Back to cited text no. 9
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.  Back to cited text no. 10
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Walton RE. The residual radicular cyst: Does it exist? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:471.  Back to cited text no. 12
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Prakash R, Shyamala K, Girish HC, Murgod S, Singh S, Rani PV. Comparison of components of odontogenic cyst fluids: A review. J Med Radiol Pathol Surg 2016;2:15-7.  Back to cited text no. 14
Johann AC, Gomes Cde O, Mesquita RA. Radicular cyst: A case report treated with conservative therapy. J Clin Pediatr Dent 2006;31:66-7.  Back to cited text no. 15
Domingos RP, Gonçalves Eduardo S, Neto Eduardo S. Surgical approaches of extensive periapical cyst. Considerations about surgical technique. Salusvita Bauru. 2004;23 (2):317-28.  Back to cited text no. 16
Dominiak M, Lysiak-Drwal K, Gedrange T, Zietek M, Gerber H. Efficacy of healing process of bone defects after apicectomy: Results after 6 and 12 months. J Physiol Pharmacol 2009;60 Suppl 8:51-5.  Back to cited text no. 17
Taschieri S, Del Fabbro M, Testori T, Weinstein R. Efficacy of xenogeneic bone grafting with guided tissue regeneration in the management of bone defects after surgical endodontics. J Oral Maxillofac Surg 2007;65:1121-7.  Back to cited text no. 18
Yoshikawa G, Murashima Y, Wadachi R, Sawada N, Suda H. Guided bone regeneration (GBR) using membranes and calcium sulphate after apicectomy: A comparative histomorphometrical study. Int Endod J 2002;35:255-63.  Back to cited text no. 19
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]


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