Management of infected radicular cyst associated with immature maxillary permanent lateral incisor: a conservative surgical approach

Abstract

Radicular cysts are the most common cystic lesions which affect the jaw. Traumatic dental injuries cause injury to the periodontal ligament and dental pulp often leads to pulpal necrosis. The necrosed pulp eventually becomes the nidus of infection and irritates the periapical epithelial cell remnants, which in turn develops into a cyst eventually. This case report presents the successful conservative surgical management of a large infected radicular cyst which was associated with traumatised, necrotic, permanent maxillary lateral incisor with open apex by Partsch II surgical procedure followed by a combination of retrograde and orthograde root canal obturation. This report will guide the clinicians in the arena of surgical endodontics in a conservative approach.

Background

Endodontic pathosis results from chronic inflammation often associated with traumatic dental injuries and microbial contamination of the root canals. Chronic inflammation of the pulp leads to necrosis of the pulp and development of periapical pathoses like abscess, granuloma, cyst, etc. The term ‘cyst’ is derived from the Greek word, ‘Kystis’, meaning ‘sac or bladder’.¹ Cyst is defined as a pathological cavity that is usually lined by epithelium and which has a centrifugal, expansive mode of growth.²

Radicular cysts are the most common cystic lesions which affect the jaw. They are most common of all the jaw cysts and comprise about 52%–68% of all the cysts which affect the human jaw.^{3 4} They arise from epithelial remnants which are stimulated to proliferate, by an inflammatory process which originates from pulpal necrosis of a non-vital tooth.⁵

Management of the radicular cyst depends on their size, procedural complexity and patient cooperation level. Usually, it is treated with simple conventional endodontic treatment but occasionally, it needs surgical intervention. The complexity of root canal anatomy like open apex and accessory canals often complicates the treatment of the cyst.

This case report describes the conservative surgical management of a large maxillary infected radicular cyst by Partsch II surgery (decompression followed by enucleation) with retrograde filling of large blunderbuss canal in relation to maxillary right lateral incisor and the results of 12-month follow-up.

Case presentation

An early adolescent male child has reported to our department with pain and swelling in the upper right front tooth region for the past 6 months. The patient gave a history of trauma to the upper front teeth due to an alleged fall injury 4 years ago. The swelling was insidious in onset and slow in progression to attain the present size. There was no relevant medical history and the patient was not allergic to any known drug.

On extraoral examination, facial asymmetry was noted and there was no cervico-facial lymphadenopathy. Approximately 3×3 cm swelling was present in the upper front teeth region with the elevated right ala of the nose, extending from the right infraorbital rim to the right side of the upper lip medially up to the lateral aspect of the nose and distally blends with the zygomatic region. The swelling was tender on palpation, soft in consistency and fluctuant with imperceptible borders.

On intraoral examination, we have found that the right upper labial vestibule got obliterated in relation to maxillary right lateral incisor, and slight palatal bony expansion was also noted. There was uncomplicated crown fracture of 11 and grade 1 mobility of 12. Brownish discolouration of crown and negative response to electric pulp testing were noted in 12. No active carious lesion was present (figure 1).

Figure 1.

Preoperative intraoral view.

The provisional diagnosis of an infected radicular cyst associated with the non-vital immature permanent maxillary lateral incisor was made.

Investigations

The patient was advised with radiographical investigations, intraoral periapical radiograph (IOPA) and orthopantomogram (OPG). IOPA reveals the maxillary right lateral incisor root was immature with blunderbuss canal and the Cvek’s root development stage was 3.⁶ There was a well-defined periapical radiolucency on 12 with the Peri Apical Index score of 5 (figure 2). OPG shows unilocular radiolucency in right maxillary region with well-defined border at the apex of 12 (figure 3).

Figure 2.

Intraoral periapical radiograph shows periapical radiolucency in 12 with open apex.

Figure 3.

Orthopantomogram shows unilocular well-defined radiolucent lesion in 12.

Differential diagnosis

Differential diagnosis of periapical abscess was made as the patient was having the pus discharge in his first visit. But after aspiration of the lesion with wide-bore needle (19 G), it yielded a blood-tinged, yellowish fluid (figure 4). It clinched the diagnosis of an infected radicular cyst clinically.

Figure 4.

Blood-tinged, yellowish aspirate of the lesion with wide-bore needle.

Treatment

Considering the size of the cyst and blunderbuss canal, treatment was planned conservatively: enucleate the lesion in two stages (Partsch II surgery) followed by retrograde mineral trioxide aggregate (MTA) apexification.

In the first stage, decompression of the cystic lesion was done under local anaesthesia (2% lignocaine with 1:80 000 epinephrine) with no. 11 surgical blade. A decompression tube was secured with ligature wire to right maxillary canine (figure 5). Access cavity was prepared in 12 and copious irrigation of the canal done with 30 mL of warm saline. Freshly mixed calcium hydroxide intracanal medicament was placed in 12 followed by the temporary restoration (Cavit, 3M, USA) of the access cavity. Parental education and patient motivation had been given regarding the treatment.

Figure 5.

Decompression of the lesion with the tube secured to maxillary canine.

After a period of 1 month, the patient was recalled for second-stage surgery. There was a drastic reduction in the size of the lesion, both clinically and radiographically. The decompression tube was removed under local anaesthesia (2% lignocaine with 1:80 000 epinephrine) and full thickness Luebke-Ochsenbein flap was elevated (figure 6). Enucleation of the shrunken cystic lesion was done in toto, followed by retrograde MTA (PPH, Cerkamed, Poland) apexification of maxillary lateral incisor (figure 7). Alloplastic bone graft (SyboGraf, nanocrystalline hydroxyapatite granules, India) blended with autologous platelet-rich fibrin (PRF) was placed in the cystic cavity (figure 8). A resorbable-guided tissue regeneration membrane (Perio-Col, India) was placed over the bone graft to prevent the long junctional epithelium formation (figure 9). Haemostasis was achieved by using sterile cotton pellets during the procedure and the suturing was done with 3-0 silk (one-half circle, reverse cutting swaged needle) (figure 10). Analgesics (tablet ibuprofen 400 mg two times per day) and antibiotics (tablet amoxycillin+clavulanic acid 375 mg three times a day and tablet metronidazole 400 mg three times a day) were prescribed for 5 days to prevent the postoperative infection.

Figure 6.

Luebke-Ochsenbein flap design.

Figure 7.

Retrograde mineral trioxide aggregate apexification.

Figure 8.

Autologous platelet-rich fibrin and nanocrystalline hydroxyapatite granules.

Figure 9.

Resorbable-guided tissue regeneration membrane placement.

Figure 10.

Suturing of the surgical site with 3-0 silk.

Enucleated specimen was sent for histopathological examination (figure 11). Histologically, the specimen shows stratified, non-keratinised, squamous epithelium with dense inflammatory cell infiltrate predominantly of neutrophils. The capsule consists of cholesterol clefts and Russell bodies which are pathognomonic of a radicular cyst (figure 12).

Figure 11.

Enucleated specimen.

Figure 12.

Histopathological view of the lesion (10×).

The patient was recalled after 1 week for custom-made gutta-percha (GP) obturation of the canal by roll cone technique. GP cones were softened with chloroform, rolled over a glass slab and checked for the fit inside the canal until they fit snugly. Then, the canal was irrigated with 20 mL of normal saline followed by obturation with custom GP cone and zinc oxide-eugenol as sealer (figure 13).

Figure 13.

Postoperative intraoral periapical radiograph after orthograde custom gutta-percha cone obturation.

Outcome and follow-up

The complete bone healing was evident in 6-month and 12-month follow-up with the absence of clinical symptoms (figures 14–16). The patient has returned to his normal routine activities.

Figure 14.

Six-month follow-up orthopantomogram.

Figure 15.

Twelve-month follow-up intraoral periapical radiograph.

Figure 16.

Twelve-month follow-up clinical view.

Discussion

Traumatic dental injuries are one of the most important causes of pulpal necrosis and the necrosed pulp acts as a source of infection and triggers the epithelial cell remnants of Malassez, which causes cyst development.^{5 7} This present case also has a history of fall injury 4 years ago, which led to the pulp necrosis of the maxillary lateral incisor and subsequent cyst development.

Nevertheless, cone-beam CT (CBCT) provides better visualisation of three-dimensional view of the bony defects than any other technique; the radiation dosage of the CBCT is significantly higher than the IOPA and OPG.⁸ Considering the potential radiation hazard to the patient and cost-effectiveness, IOPA and OPG were advised for the diagnosis and also during follow-up visits.

Partsch II surgery, also known as Waldron’s procedure, was performed in this case, considering the large size of the lesion. In this method, surgery is done in two stages, which consist of initial decompression in the first stage, followed by complete enucleation of the lesion in the second stage. Decompression relieves the intracystic pressure and accelerates the shrinking of the lesion.⁹

Calcium hydroxide is being used as intracanal medicament widely because of its high pH (pH >12) and antimicrobial action. Recent research shows calcium hydroxide is equally efficacious as triple antibiotic paste in antimicrobial activity and promotes periapical healing.¹⁰

MTA, a biocompatible material, can be used to create a physical barrier at the root apex. It also helps in the formation of bone and periodontium around its interface.¹¹ Although MTA has good sealing ability as a root-end filling material, the main disadvantage of MTA is its difficult manipulation. Placement of the material in a wide open area is a challenging task and also there is a risk of extruding the material into periapical tissues.¹² Presence of the blunderbuss canal and the large periapical lesion make the orthograde MTA apexification difficult. It takes longer healing time for the complete resolution of the periapical lesion by conventional endodontic treatment. The combined retrograde and orthograde root canal obturation was performed in this case as the lesion was larger in size. We hypothesise that this combined approach provides (1) reduction in the number of visits, (2) immediate results, and (3) good bone healing as the lesion is enucleated and filled with bone graft.

An in vitro study states that thermoplastic GP has superior sealing ability, and adaptation with the canal walls with absence of voids compared with cold lateral condensation and flowable GP technique.¹³ The main drawback of the thermoplasticised GP obturation method requires expensive armamentarium. Custom GP using roll cone method is an inexpensive technique which also provides better adaptation to the canal walls.¹⁴ Thus, the obturation of the root canal was performed by roll cone method in orthograde manner considering the cost-effectiveness in this case.

PRF has good healing potential with various growth factors. It accelerates the new bone formation and acts as a scaffold due to its dense fibrous nature.¹⁵ It releases growth factor for longer period as it gets slowly absorbed by the host. PRF, in combination with bone mineral, had the ability to increase the regenerative effects in intrabony defects.¹⁶ The bone cavity was filled with the mixture of nanocrystalline hydroxyapatite alloplastic bone graft and autologous PRF to eliminate the dead space formation and increase the bone regeneration in this present case. Complete bone healing was well appreciated in the 6-month and 12-month follow-up visits.

Patient’s perspective.

My son was having severe pain and swelling in the upper front tooth region 1 year back. After that we rushed to the dental hospital. The doctors examined my son and advised few radiographs, then we got to know that my son having cyst inside the upper jaw bone. Doctors advised us about the surgery of the cyst in conservative manner along with root canal treatment of the affected tooth. Now my son is perfectly alright and doing his day-to-day work after surgery.

Learning points.

• A combined orthograde/retrograde approach can be a good option while treating a periapical cyst associated with immature tooth.

• Partsch II (Waldron’s procedure) is a less-invasive method of managing cysts in children.

• Mineral trioxide aggregate has good biocompatibility and better sealing property as a root-end filling material which provides greater results both clinically and radiographically.

Ethics statements

Patient consent for publication

Parental/guardian consent obtained.