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An Ambiguous Entity-A Case Report

Rinisha Sinha1*, Pranave P2, Pramod Waghmare3 1Postgraduate Student, Department of Periodontology and Oral Implantology, Bharati Vidyapeeth Deemed to be University, Dental College and

Hospital, Pune, India. 2Postgraduate Student, Department of Oral and Maxillofacial Surgery, Bharati Vidyapeeth Deemed to be University, Dental College and Hospital,

Pune, India. 3Professor, Department of Periodontology, Bharati Vidyapeeth Deemed to be University, Dental College and Hospital, Pune, India.

*Corresponding Author: Rinisha Sinha, Postgraduate Student, Department of Periodontology and Oral Implantology, Bharati Vidyapeeth

Deemed to be University, Dental College and Hospital, Pune, India.

Received date: February 25, 2021; Accepted date: June 14, 2021; Published date: June 16, 2021

Citation: R Sinha, P Pranave, P Waghmare. (2021) An Ambiguous Entity-A Case Report. International Journal of Clinical Case Reports and

Reviews. 7(3); DOI: 10.31579/2690-4861/120

Copyright: © 2021 Rinisha Sinha, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which

permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Purpose: This report discusses the literature review in comparison with the current case’s findings in detail

as well as the indications for guided bone regeneration to be done in the same patient after a follow-up of 6

months. We reported this case due to its uniqueness in terms of the etiology, clinical and radiographic findings,

and management.

Method: We account a case of 24-year-old male patient who reported significant swelling in the upper right

region of the mouth that slowly increased to the present size. On evaluating the panoramic radiograph, there

was well-defined radiolucency seen.

Result: Complete enucleation of the cyst along with the extraction of the involved teeth was done and the

healing was satisfactory.

Keywords: periapical cyst, enucleation, biopsy, extraction, guided bone regeneration

Clinical Significance: Some diagnosis is in a disguise and only a

detailed thorough investigation can reveal the true identity. Not every

finding works according to the textbook. Thereby, this case report shall

be putting the same into limelight.

Introduction

The most common explanation for chronic swellings of the jaws is cysts.

The term “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].

Amongst the various types of odontogenic cysts observed, [3] periapical

cyst is one of the most common, which is a subtype of an inflammatory

cyst. It is originated from the epithelium and is clinically asymptomatic

but can result in a slow-growth tumefaction in the affected region.

Radiographically, the classic description of the lesion is 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 along with its peculiar

characteristics and its successful uneventful management.

Case Report

This case relates to a 24-year-old male [Fig. 1], who presented to the

Department of Periodontology and Oral Implantology, complaining of a

significant swelling in the upper right region of the mouth for 1 week

which slowly increased to present size. His past medical history was non-

contributory. The patient was moderately built and nourished and was

well-oriented.

On clinical examination of the extraoral features, there was mild to

moderate swelling on the right zygomaxillary region with the skin

appearing to be normal. On palpation, the swelling appeared hard and

mild tenderness was felt by the patient. Lymph nodes were non-palpable.

Intraoral examination revealed diffuse swelling, measuring 3 cm x 2 cm,

extending from the distal of 13 to mesial of 17 on the upper buccal mucosa

[Fig. 2].

The labial vestibule was obliterated by the swelling with no discharge. All

the involved teeth were vital and non-tender to pressure and percussion.

Grade I gingival enlargement was observed concerning 14 and grade II

gingival enlargement was seen concerning 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 [Fig. 3(a), 3(b)

& 3(c)].

Radiographic examination revealed a single, large, well-defined,

completely radiolucent lesion in the right side of the maxilla, associated

with the periapical region of teeth 13,14,15,16,17 and over-retained root

piece of primary tooth 55 [Fig. 4]. There was thinning, expansion, and

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perforation 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.

Routine laboratory investigations were under normal limits. Fine needle

aspiration cytology [Fig. 5] revealed cheesy, turbid brown-colored fluid,

consisting of sheets of neutrophils admixed with few macrophages. The

cytological picture was evocative of an acute inflammatory lesion.

Based on clinical, radiological, and analysis of aspirate, a provisional

diagnosis of the infected periapical cyst was made. After surgical

enucleation [Fig. 7(a) & 7(b)] and biopsy [Fig. 6], the histopathological

picture shows cystic epithelial lining and fibro cellular connective tissue

stroma.

It revealed cuboidal to low columnar hyperchromatic basal cells in the

epithelium. Underlying connective tissue was infiltrated with diffuse,

dense chronic inflammatory cells, predominantly lymphocytes, and

plasma cells. Increased vascularity was seen with endothelial cell

proliferation that was filled with extravasated blood. Numerous

multinucleated giant cells and few hemorrhagic areas were also seen.

Histological features confirmed the clinical diagnosis of Infected

Periapical Cyst.

Given its clinical characteristics, the differential diagnosis of periapical

cyst includes dentigerous cyst, Pindborg tumor, periapical cementoma,

traumatic bone cyst, ameloblastoma, odontogenic keratocyst, and

odontogenic fibroma.

The patient was advised for surgical excision and biopsy. Careful

enucleation of the cyst was performed alongside the extraction of 14, 15,

16 under local anesthesia [Fig. 8].

Intact bone was present all-round the apices of adjacent teeth; hence no

postoperative endodontic treatment was performed on other teeth.

Excised tissue was sent for histopathological investigation. Necessary

prescriptions and postoperative instructions were given [Fig. 9].

Postsurgical follow-up after 15 days showed considerable reduction in the

size of swelling with prompt healing of surgical site. At 2 months follow-

up, no recurrence was observed [Fig. 10]. Patient’s every month follow-

up is being carried on.

Figure 1: Preoperative Extraoral Photograph

Figure 2(a): Intraoral image showing swelling in the right zygomaxillary region

Figure 2(b): Intraoral image showing no apparent swelling on the palatal aspect

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Figure 3(a) & (b): CBCT- Reconstructed Panoramic and 3D

Figure 3(c): CBCT- Cross-sectional images of 15, 16 and 17

Figure 4: Pre-operative Orthopantomogram

Figure 5: Fine needle aspiration cytology specimen

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Figure 6: Biopsy specimen

Figure 7(a): Surgical Enucleation

Figure 7(b): Bone defect after enucleation

Figure 8: Extracted 15, 16, 17

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Figure 9: Post-suturing

Figure 10: Follow-up Picture (2 months post-op)

Discussion

Inflammatory jaw cysts comprise a collection of odontogenic lesions.

They originate as epithelial residues within the periodontal ligament.

Periapical cysts are diagnosed either during a routine radiographic

examination or following their acute exacerbation [5].

The prevalence of the periapical cysts in the maxilla is 60% as compared

with the mandible and is associated with buccal or palatal enlargement

[4]. The present case was associated with a huge buccal swelling, slightly

evident extraorally and involving 15, 16, 17 intraorally. Periapical cysts

grow slowly and lead to mobility, root resorption, and displacement of

teeth. Once infected they may lead to pain and swelling and patients

become aware of the problem [6]. In this case no mobility, and/or root

resorption was seen despite the presence of a large chronic infected cystic

lesion. But the root of tooth 15 showed displacement in buccal direction.

Periapical cystic lesions undergo asymptomatic evolution with

crepitations followed by erosion and fluctuation of the overlying soft

tissue. The bone in the surrounding area will be thinned out with

springiness and eggshell crackling, leading to cortical plate expansion. In

the present scenario, the buccal and palatal cortical plates exhibited the

same.

Radiographically, the periapical cyst appears as round or pear-shaped

unilocular radiolucency at the apex of a non-vital tooth. The chronic

periapical cyst may result in the resorption of offending tooth roots [7].

Despite being infected, the present case had a partially well-defined

border and completely radiolucent internally.

These cysts are generally associated with the root apex of a carious or

fractured tooth due to the presence of necrotic pulp. Massive dental cysts

sometimes may extend into the sinus away from the original epicenter [7]

and sometimes, present as a huge multilocular periapical cyst [8]. The

present case was associated with the retained root stump of a deciduous

molar.

Simon9 described two types of periapical cysts. One form is a true cyst

which contains a closed cavity entirely lined by the epithelium and the

other form is a periapical pocket cyst also known as the bay cyst.

Histopathologically, periapical cysts are lined completely or partially by

stratified squamous epithelium. The lumen of a cyst contains fluid with a

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small concentration of protein and a collection of cholesterol clefts

(Rushton bodies) with multinucleated giant cells. The deposits of

cholesterol crystals arise from the disintegration of red blood cells,

lymphocytes, plasma cells, and macrophages [11]. In our case, the

histopathological finding revealed acute and chronic inflammatory

infiltrate without any Rushton bodies.

A few well-documented cases [12, 13] indicate that squamous carcinoma

occasionally arises from the metaplastic changes in the epithelial lining

of the periapical cysts. At present, there is no concrete evidence that cyst

epithelium is at particular risk of carcinomatous transformation and no

justification regarding cysts as precancerous lesions.

The recommended treatment option available for periapical cyst is the

conventional endodontic approach combined with decompression [14] or

surgical enucleation of a cyst with the extraction of the offending tooth.

Some authors are of the view that suspected radicular cysts must be

enucleated surgically to remove all epithelial remnants [15]. However, in

large lesions the endodontic treatment alone is not efficient and it should

be associated with decompression or a marsupialization or even with

enucleation [16, 17]. Lesions that fail to resolve with endodontic therapy

may be successfully managed by extraction of the associated non-vital

teeth and curettage of the epithelium in the apical zone [18]. The other

options suggested are surgical decompression to reduce the size of the

lesion before marsupialization or complete enucleation is planned, to

reduce the chances of damage to other teeth or anatomic structures [19].

Nair1, 10 considered that the type of cyst was an important, and the true

cyst is self-sustaining and may persist even after endodontic treatment.

As the present case represented a giant infected true cyst, surgical

enucleation along with extraction of offending teeth was considered as the

successful treatment modality [21]. Despite using the conventional

surgical technique, the vitality of the adjacent teeth and integrity of vital

anatomical structures were not violated.

Enucleation of large cysts in the jaws is an invasive method that may lead

to complications such as damage of the adjacent teeth or anatomic

structures, but concurrent and less invasive surgical techniques for

treating large radicular cysts have been developed [20].

To aid the reparation process, after surgical enucleation, guided bone

generation methods are in use. From futuristic point of view, guided bone

regeneration is indicated in the current scenario after a follow-up of 6

months which we will be doing in another 4 months [22]. Few studies

believe that regenerative techniques are not superior, either about the

speed or quality of healing [23]. In contrast, other studies [22, 24] stated

that conventional treatment results were less predictable in comparison

with cases in which regeneration methods were used.

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.

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