MANAGEMENT OF A LARGE CYST IN MAXILLARY REGION: A

CASE REPORT
1Moh. Azhary S. Nohu, 1Mohammad Gazali, 1Irfan Rasul

1Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Hasanuddin

University, Makassar, Indonesia

ABSTRACT

Introduction: Radicular cysts are the most common odontogenic cyst. It is an inflammatory
cyst that is always associated with non-vital teeth. This is a case report of radicular cysts in a
38-year-old man, symptoms-free. An asymmetrical face was found in the clinical examination
of region zygoma dextra with size ± 3 x 2 x 1 cm. No cavities were found on region teeth 13-
17. There is a history of trauma. The patient was treated with enucleation, curettage, and
extraction teeth 15 - 17 under general anesthesia.
Case: A 37-year-old male patient came with complaints of enlargement at gums on the
maxillary right side since ± 1.5 years ago, but there were no complaints of pain. History of
dental trauma in childhood was recorded. History of systemic disease in denial.
Discussion: The management of radicular cyst enucleation will be discussed. Based on this
case, non-vital tooth create radicular cysts due to a history of trauma.
Conclusion: A radicular cyst is a lesion that develops around the root of a tooth as a result of
dental trauma. Dental trauma can be caused by a variety of factors, including accidents,
physical injuries, and faulty dental care procedures.

Keywords: Dental Trauma, Enucleation, Radicular cyst,

Corresponding Author: Mohammad Azhary Syaifullah Nohu

Email: arynohu@yahoo.com
 MANAJEMEN ENUKLEASI KISTA RADIKULAR BESAR PADA
REGIO MAKSILA: LAPORAN KASUS
1Moh. Azhary S. Nohu, 1Mohammad Gazali, 1Irfan Rasul

1Departemen Bedah Mulut dan Maksilofasial, Fakultas Kedokteran Gigi, Universitas

Hasanuddin, Makassar, Indonesia

ABSTRAK

Pendahuluan: Kista radikular adalah kista odontogenik yang paling umum terjadi. Ini adalah
kista inflamasi yang selalu dikaitkan dengan gigi non-vital. Pada laporan kasus ini dengan kista
radikular pada pria berusia 38 tahun, tanpa keluhan. Wajah asimetris ditemukan dalam
pemeriksaan klinis daerah zygoma dextra dengan ukuran ± 3 x 2 x 1 cm. Tidak ada lubang
kavitas yang ditemukan pada gigi daerah 13-17. Ada riwayat trauma. Pasien dirawat dengan
enukleasi, curettage, dan ekstraksi gigi 15 - 17 dalam general anestesi.
Kasus: Seorang pasien laki-laki berusia 37 tahun datang dengan keluhan pembesaran gusi
di sisi kanan rahang atas sejak ± 1,5 tahun yang lalu, tetapi tidak ada keluhan rasa sakit.
Riwayat trauma gigi saat masih kecil. Riwayat penyakit sistemik disangkal.
Diskusi: Manajemen enukleasi kista radikular akan dibahas. Berdasarkan kasus ini, gigi non-
vital menyebabkan kista radikular karena adanya riwayat trauma.
Kesimpulan: Kista radikular adalah lesi yang berkembang di sekitar akar gigi sebagai akibat
dari trauma gigi. Trauma gigi dapat disebabkan oleh berbagai faktor. termasuk kecelakaan,
cedera fisik, dan prosedur perawatan gigi yang keliru.

Kata kunci: Enukleasi, Kista Radikular, Trauma Gigi

Korespondensi: Mohammad Azhary Syaifullah Nohu

Email: arynohu@yahoo.com
INTRODUCTION :

Odontogenic cysts are unique disorder that affects oral and maxillofacial tissues. They

arise as a result of inflammatory or developmental pathogenic causes associated with the

epithelium of tooth-forming apparatus. The 4 most frequently occurring odontogenic cysts are

radicular, dentigerous cysts, residual cysts, and odontogenic keratocyst (OKC). (1,2)

The radicular cyst is a common inflammatory odontogenic cyst, which arises from the

epithelial rest of Malassez due to pulpal necrosis. World Health Organization, classified cysts

in the jawbones as a developmental, neoplastic, and inflammatory origin. Root canal infections

may cause radicular cysts, few radicular cysts can be treated by conventional root canal

therapy, and a large radicular cyst is managed surgically. (3,4)

Radicular cysts are the most common cyst of the jaw and are caused by inflammatory

processes. All radicular cysts are associated with nonvital teeth and identified at the apices of

teeth. Either carious process or trauma triggers the residual epithelial remnants at the periapical

region and stimulates and proliferates the remnants, leading to cyst formation. These cysts are

well identified through radiological investigations. (1,5)

CASE REPORT :

A 37-year-old male patient came with complaints of enlargement of the gums of the

maxillary right side since ± 1.5 years ago, but there were no complaints of pain. Initially, a

small lump appeared elongated and filled with fluid, and grew until now. History of swelling

ever enlarged but gradually decreased. ± 1 year ago, the patient went to a private practice

dentist and was given 2 types of drugs namely Metronidazole 500 mg and Exaflam 50 mg. No

salty liquid coming out of the mouth. There was no history of discharge from the nose. No

history of weight loss. History of biopsy incision surgery at RSGMP Unhas in January 2022.

There is no history of drug and food allergies. History of systemic disease in denial. Currently,

the patient is not in a state of fever, cough, flu, runny nose, and diarrhea.

On physical examination, vital signs were normal. From the extraoral examination, the

face appears asymmetrical with normal mouth openings. A vitality test using Chlorethyl was

negative, showing that teeth 13-17 remain non-vital. There were no signs of skin petechiae.
Anemic conjunctiva was not found. Lymph node examination was within normal limits (Figure

1).

Intraoral examination showed an enlargement of the ar gingiva to the buccal vestibule of

teeth 13-17 with a size of ± 5 x 3 x 5 cm, hard consistency, crepitation (+), palpation pain (-),

color and temperature the same as the surrounding tissue. (Figure 2).

During CBCT X-Ray it was found that there was a suspected aggressive lesion extending

from the alveolar bone of dentition 14-17 to the sinonasal area with a suspected benign cyst or

neoplasm as an extrinsic lesion towards the maxillary sinus with a differential diagnosis:

odontogenic keratocyst (OKC), and adenomatoid odontogenic tumor (AOT). No radiographic

signs suggestive of the suspected radicular cyst (teeth 14-17 show no crown lesion involving

the pulp). (Figure 3).

Subsequently, the patient was referred to the clinical pathology department for tissue

examination, and the result was a radicular cyst. The patient was then scheduled for surgical

removal of the cyst (enucleation). (Figure 4).

Based on histopathological findings, it was diagnosed as a “radicular cyst” (Figure 5).

After being controlled post-operation day 3, 7, 14. The patient was referred to the

prosthodontics department to make an obturator and perform the insert of the obturator on post-

operation day 30. (Figure 6)

DISCUSSION :

The cyst is defined as a pathological cavity having fluid, semifluid or gaseous contents

and which is not created by the accumulation of pus. A Radicular cyst is considered an

inflammatory cyst because of the caries tooth or trauma. The etiology of radicular cyst focuses

on trauma or dental caries, which ends up in pulpal necrosis where the infection travels to the

tooth apex of the root and forms periapical granuloma periapical cyst secondary to the

provocation of epithelial rest of Malassez through the local inflammation. (3)

Inflammatory jaw cysts comprise a group of odontogenic lesions. They originate as

epithelial residues in the periodontal ligament due to apical periodontitis following the death and
necrosis of the dental pulp. Radicular cysts are diagnosed during a routine radiographic

examination or after an acute exacerbation. (6)

The carious or traumatic condition leads to the death of dental pulp tissue. However,

carious or discolored teeth are often associated with Radicular Cysts. The inflammatory

stimulus from a pulpal region reaches a periapical region to cause stimulation of epithelial cell

rests of Malassez, eventually forming a Radicular Cyst. The symptoms of the Radicular Cyst

depend on the status of inflammation. Careful palpation over the mucosa at the periapical zone

of the offending tooth may provide a clue to swelling, which may guide cortical plate expansion.

Radicular Cyst are most often associated with unicortical plate expansion; that is, either

buccal/labial or palatal/lingual cortical bones. Bilateral occurrence of Radicular Cysts has also

been documented. A tooth with acute inflammatory exacerbation is symptomatic and presents

with pain or discomfort. Displacement of the tooth may be seen clinically when the cyst is large.

Pulp testing and radiography are compulsory for diagnosing Radicular Cyst. Teeth associated

with Radicular Cysts must be nonvital and do not respond to thermal or electric pulp testing

methods. Lymph nodes must be palpated during clinical examination. Regional lymph nodes

may be enlarged in cases of Radicular Cyst. Radicular Cysts are rare in deciduous tooth

because deciduous teeth are usually resorbed. However, a radiolucent zone may be seen at

the bifurcation or inter-radicular space of the deciduous tooth when infected. (1,7)

Pulp testing, radiographs, and histopathologic evaluation are helpful in achieving an

accurate diagnosis. Radicular cysts are radiologically recognized by well-defined, well-

circumscribed, unilocular radiolucency that is closely associated with the apex of the affected

tooth. Loss of lamina dura and a faint or thin radiopaque line (sclerotic border) that encircles

the cystic region are also important radiographic markers for securing a diagnosis. Root

resorption can be seen in cases with cytokine-related inflammatory action of the cyst. Cases

with large radiolucent areas can be observed when the lesion is aggressive or left untreated for

a long period. Radicular cysts with large radiolucency often flatten out as they reach the

adjacent tooth; Radicular cysts rarely displace the adjacent tooth. Very few Radicular Cyst

cases have reported radiopaque foci within the radiolucent area (8)
 Radicular cysts are usually managed with conventional root canal treatment with

periapical surgery; that is, apicoectomy (removal of tooth apex). Extraction with curettage is

another mode of treatment. Inadequate curettage may lead to the persistent radiolucent cavity

(9,10)

The pathogenesis of radicular cysts has been described in three phases; phase of

initiation, cyst formation, and enlargement. However, two theories exist in cyst cavity formation.

The “nutritional deficiency theory” is based on devoid of nutritional deficiency and the“abscess

theory” that the proliferating epithelium lines an abscess cavity formed by tissue necrosis and

lysis because of the innate nature of the epithelial cells to cover exposed connective tissue

surfaces then the cyst grows by osmosis. Later diffuses into the cyst cavity to raise the

intraluminal hydrostatic pressure well above the capillary pressure. The increased intracystic

pressure may lead to bone resorption and expansion of the cyst. Pocket cysts with a lumen

open to the necrotic root canal can become larger than usual because osmotic pressure plays

a potential factor in the development of radicular cysts. (3,11)

Clinically a patient with a periapical cyst has no symptoms until there is an acute

inflammatory exacerbation, and the cyst reaches a large size. Movement and mobility of

adjacent teeth can occur as the cyst enlarges. The radiographic feature reveals a well-defined

unilocular radiolucency located periapical to a tooth with pulpal involvement. (3,12)

On histopathological examination, most of the radicular cysts are lined wholly or partly,

by nonkeratinized-stratified squamous epithelium, this lining may be discontinuously ranging

from 1 to 50 cell layers thick. In the early stages, the epithelial lining may show proliferation and

arcading pattern with intense inflammatory infiltrate. In enlarging cysts, the lining becomes

quiescent and fairly regular with a certain degree of differentiation to resemble simple stratified

squamous epithelium. If present, Keratin formation rarely affects only a part of the cyst wall. In

the proliferating epithelium, the inflammatory cell infiltrate consists predominantly of

polymorphonuclear leukocytes. The adjacent fibrous capsule is infiltrated by chronic

inflammatory cells. (13)

 In the literature, different therapies are proposed, such as conservative root canal

treatment without adjunctive therapy, decompression technique, active nonsurgical

decompression technique, aspiration through the root canal technique, marsupialization, apical

resection, and surgical enucleation. (14)

This case shows that radicular cysts do not always occur in non-vital teeth. but it can

also occur in vital teeth.

CONCLUSION :

A radicular cyst is one of the most common, which is, in turn, a subtype of inflammatory

cyst. The progression of the cyst is initiated by pulpal necrosis followed by a periapical

inflammatory reaction. (15)

In this case, a radicular cyst was found to occur on a vital tooth. based on the history,

clinical examination, and supporting examinations, there were no signs supporting the

suspicion of a radicular cyst.

ACKNOWLEDGEMENT :

By the making of the case report, we would like to take this opportunity to thank you for your

effort and expertise as a reviewer.

Your help enabled us to complete this case report

Reviewers:

1. Moh. Gazali, drg., MARS., Sp.B.M.M., Subsp. T.M.T.M.J. (K)., University of Hasanuddin

Makassar, Indonesia

2. Irfan Rasul, drg., Ph.D., Sp.B.M.M., Subsp. C.O.M. (K)., University of Hasanuddin

Makassar, Indonesia
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FIGURES AND TABLES :

A B C D

Figure 1. A) Lateral view, B) Frontal view, C) Lateral view, D) Worm view

Figure 2. Intraoral images of the patient

A B C

Figure 3. CBCT X-Ray A) Axial view, B) Frontal view, C) Sagital view

Figure 4. Intra-operation (enucleation)

 Figure 5. Epithel of a cyst’s layer squamose structure

Figure 6. Controlled post-operation day 3, 7, 14, and insert of obturator on the post-operation day 30