|Year : 2014 | Volume
| Issue : 2 | Page : 61-64
Radicular cyst of maxillary primary tooth: Report of two cases
Vinod Vijay Chander1, Sridevi Koduri1, Seema Basoya2, Lavina Arya1
1 Department of Oral Medicine and Radiology, Hospital and Research Institute, Gurgaon, Haryana, India
2 S.G.T. Dental College, Hospital and Research Institute, Gurgaon, Haryana, India
|Date of Web Publication||10-Mar-2015|
Department of Oral Medicine, S.G.T. Dental College, Hospital and Research Institute, Gurgaon, Haryana
Source of Support: None, Conflict of Interest: None
Radicular cyst is one of the most common odontogenic cysts of the jaws, but those arising from primary teeth are very rare. This article reports two such rare cases incidentally affecting deciduous maxillary teeth.
Keywords: Deciduous, periapical cyst, primary tooth, radicular cyst
|How to cite this article:|
Chander VV, Koduri S, Basoya S, Arya L. Radicular cyst of maxillary primary tooth: Report of two cases. J Oral Res Rev 2014;6:61-4
|How to cite this URL:|
Chander VV, Koduri S, Basoya S, Arya L. Radicular cyst of maxillary primary tooth: Report of two cases. J Oral Res Rev [serial online] 2014 [cited 2020 Apr 7];6:61-4. Available from: http://www.jorr.org/text.asp?2014/6/2/61/152911
| Introduction|| |
Radicular cysts are the most common inflammatory cysts and arise from the epithelial rests in the periodontal ligament as a result of periapical periodontitis following death and necrosis of the pulp. They are also known as periapical cyst, apical periodontal cyst, root-end cyst. Although dental caries is very common in children, however radicular cysts affecting deciduous dentition appear to be rare with the incidence being as low as 0.5-3.3%.  We report here two such rare cases of radicular cysts associated with deciduous maxillary first molar.
| Case Reports|| |
Male, aged 6 years reported to the department with the complaint of pain and swelling in the left back region of the upper jaw since 20 days. Patient had episodes of toothache in the same region, which was localized, intermittent, mild in nature and relieved on taking analgesics. Patient had no previous history of swelling, 20 days back he noticed swelling on the left middle third of face preceded by pain, which gradually increased in size, and there was no associated history of fever, pus discharge or other associated symptoms. There was no history of any previous dental management pertaining to the complaint.
Extraoral examination revealed a swelling in the left middle third of the face, which was diffuse, nontender and bony hard [Figure 1]a]. Intraoral examination revealed, root stump in relation to deciduous left maxillary first molar and intraoral swelling in left buccal vestibule, extending from the mesial surface of deciduous left maxillary lateral incisor to the mesial surface of deciduous left maxillary second molar. Swelling was variable in consistency, being compressible and nonfluctuant in the anterior region; whereas it was hard, noncompressible and nonfluctuant in relation to posterior aspect along with expansion of buccal cortical plate in relation to deciduous left maxillary first and second molar [Figure 1]b]. Based on the findings, provisional diagnosis of periapical cyst in relation to deciduous left maxillary first molar was arrived at. Fine-needle aspiration cytology was performed as chair side investigation with 24 gauze needle, 1.0 ml straw colored fluid was aspirated and subjected to cytological examination, which showed inflammatory cells suggestive of an inflammatory cyst [Figure 1]c]. Radiographic investigations included periapical radiograph, orthopantomograph (OPG) and occlusal view.
|Figure 1: Extraoral photograph Case 1 showing a swelling in the left middle third of face, (a) intraoral photograph Case 1 showing swelling obliterating the left buccal vestibule (b), fine-needle aspiration cytology done with 24 gauze needle yielded 1.0 ml straw colored fluid (c)|
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Radiographs revealed well-defined periapical radiolucency in relation to deciduous left maxillary first molar extending till the tooth bud of permanent left maxillary canine, and associated with the root resorption of deciduous left maxillary canine [Figure 2]a]. The occlusal radiograph revealed the expansion of the buccal cortical plate with displacement of the permanent tooth bud permanent left maxillary first premolar [Figure 2]b]. OPG revealed a well-defined periapical radiolucency in relation to deciduous left maxillary first molar and accentuation of crown formation with respect to permanent left maxillary first premolar [Figure 2]c].
|Figure 2: Intraoral periapical revealed a well-defined periapical radiolucency in relation to deciduous left maxillary first molar extending till the tooth bud of permanent left maxillary canine (a) maxillary occlusal crosssection view revealed the expansion of the buccal cortical plate with displacement of the permanent tooth bud permanent left maxillary first premolar (b) orthopantomoraph showing a well-defined periapical radiolucency in relation to deciduous left maxillary first molar and accentuation of crown formation with respect to permanent left maxillary first premolar (c)|
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Surgical enucleation under local anesthesia was planned, the cyst was enucleated along with the removal of deciduous left maxillary canine and first molar, the tooth bud of permanent left maxillary first premolar was not removed and left in place and the sample was sent for histopathological examination [Figure 3]a and b].
|Figure 3: Enucleation of cyst, (a) enucleated cyst, (b) histhpathological features showing epithelium and connective tissue capsule with arcading pattern of epithelium (c)|
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Histopathological examination showed few cell layered epithelium and connective capsule. Epithelium exhibited arcading pattern in few areas. The connective tissue exhibited dense inflammatory cell infiltrate, blood vessels and bundles of collagen fibers suggestive of periapical cyst [Figure 3]c].
Male, aged 9 years reported to the department with the complaint of swelling in the right upper region of the jaw since 20 days. There was no history of any associated symptom or any previous dental management pertaining to the complaint.
Extraoral examination revealed a diffuse swelling obliterating the right nasolabial fold. On palpation, it was nontender and hard in consistency [Figure 4]a].
|Figure 4: Extraoral photograph Case 2 showing a diffuse swelling in right middle third of face. (a) Intraoral photograph Case 2 showing a dome shape swelling evident on the right upper vestibule extending from the maxillary labial frenum to the right maxillary buccal frenum, (b) right maxillary lateral occlusal view revealed well-defined periapical radiolucency in relation to deciduous right maxillary first molar of approximately 1.5 cm in diameter, (c) histopathology showing few layers of epithelium and connective tissue capsule with the cystic lumen (d)|
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Intraoral examination revealed root stump in relation to deciduous right maxillary first molar. Dome shape swelling evident on the right upper vestibule extending from the maxillary labial frenum to the right maxillary buccal frenum [Figure 4]b]. On palpation swelling was nontender, yielding with pressure and expansion of buccal cortical plate was also appreciated. Based on the above clinical findings like painless swelling, cystic consistency and buccal cortical plate expansion, the diagnosis of periapical cyst in relation to deciduous right maxillary first molar was arrived at. Aspiration of the swelling was done on the chair side, which yielded 2 ml straw colored fluid showing inflammatory cells on cytological examination suggestive of an inflammatory cyst. The radiographic investigations included right lateral maxillary occlusal view, which revealed well-defined periapical radiolucency in relation to deciduous right maxillary first molar of approximately 1.5 cm in diameter [Figure 4]c].
Surgery was planned for the patient, the cyst was enucleated under local anesthesia along with removal of deciduous right maxillary first molar, with the tooth bud of permanent right maxillary first premolar left in place, the sample was sent for histopathological examination, which showed few layers of epithelium and connective tissue capsule with the cystic lumen [Figure 4]d].
| Discussion|| |
Inflammatory jaw cysts comprise a group of lesions that arise as a result of epithelial proliferation within an inflammatory focus due to a number of causes. Radicular cysts are the most common inflammatory cysts and those arising from deciduous teeth are reported to occur in mixed dentition period with an incidence of 0.5-3.3%.  and a male predilection of 1.6:1.  Very few cases of radicular cysts are seen in the first decade after which there is fairly a steep rise with a peak frequency in the third decade. Lustmann and Shear  in an extensive review from 1898 to 1985 found 51 cases and Nagata et al.  in their review reported 112 cases through 2004. Various reasons cited for this relative rarity include presence of deciduous teeth for a short time, easy drainage in deciduous teeth due to the presence of numerous accessory canals and a radicular radiolucency in relation to deciduous teeth are usually neglected.
The most commonly involved deciduous teeth are mandibular molars (67%), maxillary molars (17%), maxillary anterior teeth (13%), followed by mandibular anterior teeth (3%),  both the patients reported by us, presented with radicular cyst associated with maxillary deciduous first molar, which in itself is a rare occurrence.
Pulpal and periapical infections in deciduous teeth tend to drain more readily than those of permanent teeth and the antigenic stimuli, which evoke the changes leading to the formation of radicular cysts, may be different. [4,5] In addition, the lesions tend to resolve on their own following the extraction/exfoliation of the associated tooth and are generally not submitted for histopathological examination. 
Radicular cyst clinically exhibits as a buccal/palatal cortical plate expansion in maxilla similar to both the cases reported here, whereas in mandible it is usually the buccal and rarely expansion of the lingual plate. At first, the enlargement is bony hard, but as the cyst increases in size, the bony covering becomes very thin, and the swelling exhibits springiness and becomes fluctuant when the cyst has completely eroded the bone. When present in the deciduous dentition it is more frequently associated with mandibular deciduous molar, with buccal expansion of bone and displacement of permanent tooth bud.
Grundy, Adkins, and Savage reported a series of radicular cysts associated with deciduous teeth that were treated endodontically with material containing formocresol which, in combination with tissue protein, is antigenic and has been shown to elicit a humoral and cell-mediated immune response. [4,7] The hypothesis stated that pulpal therapeutic agents may cause antigenic necrotic materials within the root canals to provide continuing antigenic stimulation in the periapical area, which causes the unusual growth, especially when the pulpal medications involve materials such as formacresol and iodoform. 
The present case reports, the lesion were associated with maxillary molar without any endodontic treatment, with buccal expansion of the cortical bone seen in both cases and displacement of the tooth bud with respect to maxillary first premolar in Case 1. The cystic lesion was not associated with the permanent tooth bud in both the cases, but with the root stump of primary molar and the histopathological features confirmed the diagnosis of radicular cyst in both the cases.
Histologically, there is no difference between the cysts of primary teeth and those of permanent teeth except for rarity of cholesterol crystal slits associated with primary teeth. This is due to the fact that the lesion associated with the primary teeth exists for shorter duration before removal in comparison to permanent teeth.  Both the cases reported above did not show any presence of cholesterol crystals, arcading pattern of epithelium was appreciated in few areas. The definitive diagnosis of radicular cyst must be based upon the clinical, radiographic and histological examination. 
The treatment of radicular cyst is enucleation of the cyst; however marsupilization can be performed in cases presenting with large lesions and in close approximity to vital structures.  Bhat et al.,  Narsapur et al.  enucleated the cyst and removed the displaced permanent tooth bud along with the cyst. The displaced tooth bud was left in place, and the cyst enucleated in present Case 1 and Case 2 similar to Gaynor  to save the permanent tooth and bring in the arch by orthodontic correction.
| Conclusion|| |
In children, swellings of shorter duration should be thoroughly evaluated, examined and investigated. As radicular cyst in the deciduous dentition not only cause extensive destruction of bone but also displaces the tooth buds of permanent teeth thereby, throwing a challenge to the clinician and pedodontist to prevent damage to permanent dentition.
| References|| |
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Lustmann J, Shear M. Radicular cysts arising from deciduous teeth. Review of the literature and report of 23 cases. Int J Oral Surg 1985;14:153-61.
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Elango I, Baweja DK, Noorani H, Shivaprakash PK. Radicular cyst associated with deciduous molar following pulp therapy: A case report. Dent Res J 2008;5:95-8.
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Narsapur SA, Chinnanavar SN, Choudhari SA. Radicular cyst associated with deciduous molar: A report of a case with an unusual radiographic presentation. Indian J Dent Res 2012;23:550-3.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]