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International Journal of Clinical Case Reports and Reviews Copy rights@ Rinisha Sinha et.al.
Auctores Publishing – Volume 7(3)-120 www.auctoresonline.org
ISSN: 2690-4861 Page 1 of 6
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
Open Access Case Report
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International Journal of Clinical Case Reports and Reviews Copy rights@ Rinisha Sinha et.al.
Auctores Publishing – Volume 7(3)-120 www.auctoresonline.org
ISSN: 2690-4861 Page 2 of 6
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
International Journal of Clinical Case Reports and Reviews Copy rights@ Rinisha Sinha et.al.
Auctores Publishing – Volume 7(3)-120 www.auctoresonline.org
ISSN: 2690-4861 Page 3 of 6
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
International Journal of Clinical Case Reports and Reviews Copy rights@ Rinisha Sinha et.al.
Auctores Publishing – Volume 7(3)-120 www.auctoresonline.org
ISSN: 2690-4861 Page 4 of 6
Figure 6: Biopsy specimen
Figure 7(a): Surgical Enucleation
Figure 7(b): Bone defect after enucleation
Figure 8: Extracted 15, 16, 17
International Journal of Clinical Case Reports and Reviews Copy rights@ Rinisha Sinha et.al.
Auctores Publishing – Volume 7(3)-120 www.auctoresonline.org
ISSN: 2690-4861 Page 5 of 6
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
International Journal of Clinical Case Reports and Reviews Copy rights@ Rinisha Sinha et.al.
Auctores Publishing – Volume 7(3)-120 www.auctoresonline.org
ISSN: 2690-4861 Page 6 of 6
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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