Case presentation

Case No:35317/23
•Name : hasmukhbhai patel
•Age : 33 YEARS
•Gender : male
•Address: Kadi
STEPS FOR APPROACHING
DIAGNOSIS
• HISTORY
• CLINICL EXAMINATION [ SIGN ,SYMPTOMS, SITE ,
TEETH VITALITY , ASPIRATION ]
• RADIOLOGICAL DIAGNOSIS.
• BIOPSY [ TO ASCERTAIN HISTOPATHOLOGICAL
FEATURES LEADING TO FINAL DIAGNOSIS]
 Chief Complain
• Patient complains of pus discharge in upper anterior
tooth region since 3-4months.
 History of present
illness
• Patient was relatively asymptomatic before 3 month then he noticed
mild pain in upper front tooth region and pus discharge from same.
• Patient gave history of trauma before 10 years where he was riding
cycle and collision with the basket of cycle. At that time there was
no loss of consciousness,extraoral bleeding or laceration but there
was presence of intraoral bleeding. He also give h/o of inward
displacement of front tooth.so at that time he visited dentist where
teeth were aligned by himwith splinting and also there was no h/o
of fracture of tooth or fracture of bone.In between these years
there was no h/o of pain ,swelling or pus discharge. But then he
observed mild pain and intermittent pus discharge and salty in taste
so he visited a private clinic where RCT[incomplete RCO] of upper
front teeth started but at that time patient was explained about the
cyst and was reffered by them to karnvati dentistry. So he reported
to department of oral surgery Karnavati School of dentistry at
10:30pm on 27/11/2023.
• Past Medical History: NRH
• Past dental history: RCT 11,21,22,23
• Prosthesis 36, 46,47

• Family history:
No relevant family history.
• Personal history:
General examination
• Patient is conscious co operative and oriented with time place and
person
• All the vital signs are in normal range.
 Extra-oral
examination
• Inspection
• facial symmetry was observed.
• No extraoral swelling.
• No sinus tract formation,bleeding or ulceration
present.
• Overlying skin and surrounding skin is normal.
• Palpaption

• All inspectory findings are confirmed on palpation.

• No rise in temperature.
• TMJ movements normal.
Intraoral examination
• Inspection
 soft tissue examination :-

swelling noted intraorally in bucal vestibule which was ill defined

• It was extending from left upper canine to right upper canine.
• Palatal swelling also present ill defined, extending anteroposteriorly
from incisive papilla to 2nd rugae ,mesiodistally from cervical margin
ofleft canine to right canine
• Reddness was present
• No sinus tract seen
• No ulceration present
Palpation
• All inspectory finding confirmed on palpation
• Swelling was hard in nature,non compressible ,non fluctuant .
• No crackling,crepitations felt.
• Both swelling were tender on palpation.
• No lymph node were palpable.
• Papilla inflammed and tender.
 Hard tissue examination:-

• Present teeth 7-1 1-8

7-1 1-8
• Stains:+
• Calculus:+
RADIOGRAPHIC INVESTIGATION:
Blood investigations :
• Complete blood count
 DIFFERENTIAL DIAGNOSIS:
• Lateral periodontal cyst,
• Globulomaxillary cyst
• Adenomatoid odontogenic tumour,
• Squamous odontogenic tumour,
• Dentinogenic ghost cell tumour
1.Lateral periodontal cyst is a developmental odontogenic cyst that is radiographically
characterised by a well-defined unilocular or pear shaped radiolucency located in an inter-radicula
location or lateral to the roots of erupted teeth.

2]. Adenomatoid odontogenic tumour has a remarkable tendency to occur in the anterior
portion of the jaws, commonly in maxilla than in mandible.
Females are affected twice as often as males.
They are relatively small and seldom exceed 3 cm in greatest diameter.
Peripheral form occurs as sessile masses usually of small size on the facial gingiva of the
maxilla

3)Squamous odontogenic tumour is haphazardly distributed throughout the alveolar process of

both maxilla and mandible, found in age groups ranging from 8 to 74 years has no sex or site
predilection.
It appears as a painless or slightly painful gingival swelling along with the mobility of involved
teeth.
Radiographic findings are not specific or diagnostic and consist of a triangular radiolucent defect
lateral to the root or roots of teeth
4) The globulomaxillary cyst (GMC) was thought to be a fissural cyst originating from epithelial
inclusions at the line of fusion Globulomaxillary cyst has a developmental origin.
Although occasionally globulomaxillary cysts have been reported between the central incisors
and lateral incisors,it is classically seen between the roots of lateral incisor and cuspid teeth .
Classical radiographic appearance of globulomaxillary cystis a well-circumscribed unilocular,
inverted pear or tear shaped radiolucency between the teeth
 Provisional diagnosis
123 123
• Radicular cyst
 Treatment plan
321 14
• RCT
• Extraction 22,23 due to poor endo prognosis and internal and external root
resorption.
• Enucleation followed by apicoectomy with retrograde filling.
Surgical management

• AIM : Therapeutic goal of any ablative surgical procedure is to remove the entire lesion and leave no cells that could
proliferate and cause recurrence of the lesion.
• ENUCLEATION AND CURETTAGE
• MARSUPIALIZATION

• Principle OF ENUCLEATION

• Enucleation allows the cystic cavity to be covered by a mucoperiosteal flap and the space fills with blood clot, which will
eventually organize and form normal bone.

• PRINCIPLE OF MARSUPIALIZATION

• An operation in which the sac of the tumor is opened and emptied of its contents then the edges are stitched to the edges of
external incision, which is kept open while inferior of the cyst suppurates and granulation occurs
CONSERVATIVE SURGICAL
TREATMENT options
• Decompression alone – placement of a drainage tube –
palliative [ decrease in lesion size ]
• Decompression followed by Enucleation along with adjuvant
therpay [ two –staged procedure ]
• Marsupialization alone [ creating pouch ]
• Waldron method
• Enucleation alone with packing , with primary closure or
with primary closure with bone grafting / reconstruction
• Enucleation along with excision of overlying oral mucosa and
application of carnoys solution or electocoagulation where
the lining is attached to soft tissues .[ stoelinga protocol ]
• Enucleation followed by various adjuvant therapies.
APPROACH

• Intraoral labial approach

• 0.5 % bupivacaine with 1: 200,000 as an local anesthetic will be infiltrated and
nasopalatine nerve block will be given AND INFRAORBITAL BLOCK .
• Full thickness mucoperiosteal flap will be raised after placing the crestal
incision which extends from 12,11,21,22,23 till 24.
• Deroofing the overlying bone will give access to cystic lesion using micromotor
and round carbide bur under continuous irrigation and currettes for separation of
cystic lining from the adjacent structures.
• The cyst along with the lining will be enucleated completely without any breach
of the cystic contents.
• The bone will be thoroughly curetted to remove residual granulation tissue.
Root end of 21 will be resected and hot burnishing will be done to seal dentinal
tubules and reduction of marginal leakage.
• Retrograde filling of 21 and an apical plug of about 4mm -5mm should be
formed
• The flap closure will be done with 3-0 silk following hemostasis .
• The cystic lesion will be submitted for histopathological examination for final diagnosis.
 conclusion
1.When radiolucency between maxillary lateral incisor and canine
is encountered, the clinician should first consider an odontogenic
origin for the lesion.
2.Rule out the other pathology which occurs at the at the same lesion
3.study and examine the clinico radiographic features and rule out the etiology......
Although we have many differential diagnoses, our working
diagnosis was a periapical cyst, so conventional treatment constituted by root canal treatment, c
enucleation, and apicoectomy was planned.