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Case Report
*Corresponding Author: Rinisha Sinha, Postgraduate Student, Department of Periodontology and Oral Implantology, Bharati Vidyapeeth Deemed to be University, Dental College and Hospital, Pune, India.
Citation: R Sinha, P Pranave, P Waghmare. (2021) An Ambiguous Entity-A Case Report. International Journal of Clinical Case Reports and Reviews. 7(2); 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.
Received: 25 February 2021 | Accepted: 14 May 2021 | Published: 17 May 2021
Keywords: periapical cyst; enucleation; biopsy; extraction; guided bone regeneration
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.
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.
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 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.
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 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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