Radicular cyst is the most common inflammatory odontogenic cyst originating from the epithelial remnants of periodontal ligament (epithelial cell rests of Malassez) following pulp necrosis. Radicular cysts are rare in the primary dentition, representing only 0·5–3·3% of the total number in both primary and permanent dentitions. Most of the radicular cysts are discovered when periapical radiographs are taken as they are asymptomatic. Radiographically, radicular cyst appears as a well-defined round or oval unilocular radiolucency with radiopaque sclerotic margin in the periapical region of involved tooth. A review of the literature shows the total cases reportable through 2004, to be about 112 and attributes 56% of them to be in response to pulp therapy.
Cyst formation in children may cause bony expansion and resorption, delayed eruption, malposition, enamel defects, or damaging of the developing permanent successors. Complete enucleation of the cyst with extraction of the associated primary teeth and preservation of the permanent teeth is one among the foremost appropriate treatment choices for these cases. Even if the initial position of the permanent teeth are very unfavorable in most cases normal alignment of the teeth will occur spontaneously. Hence, the purpose of this article is to report a rare case of a radicular cyst associated with mandibular left first primary molar and its enucleation under general anesthesia.
A 7-year-old male patient reported to the Department of Pedodontics with the chief complaint of swelling in the lower left back tooth region since 11 days. Past dental history revealed that swelling was initially small, which gradually increased to the present size. There was no history of pus discharge and ulceration and the swelling was associated with pain, which was continuous, dull, and mild in nature. On extraoral examination, swelling was appreciable in lower left side of face [Figure 1] extending from corner of mouth to the body of the mandible, tenderness present over swelling region and raised temperature over that area.
Intraoral examination revealed grossly decayed left primary first molar with buccal cortical plate expansion [Figure 1]. Grade 1 mobility with respect to 31, 32, and Grade 2 mobility with respect to 33 was observed.
Orthopantomogram revealed radiolucency involving enamel, dentine, and approximating pulp in relation to 74 and deviation in the path of eruption of 34 [Figure 2a]. Periapical radiolucency of about 8 × 5 cm in dimension, involving both the mesial and distal roots of 74 along with a thin radiopaque border was noticed, suggesting a cystic lesion. Radiolucency was clearly appreciated in CT scan views [Figure 2b, c].
On aspiration, there was blood mixed with fluid suggestive of infected radicular cyst [Figure 3a].
Clinical, radiographic examination, and excisional biopsy reports were suggestive of radicular cyst associated with mandibular left first primary molar. The histopathological examination confirmed the provisional diagnosis of a radicular cyst. It showed the presence of stratified squamous epithelium with sub-adjacent granular tissue and inflammatory infiltration. Considering the age of the patient and the size of the lesion, cyst enucleation was planned under general anesthesia.
Consent was taken from the patient's parents and surgery was scheduled. The involved teeth were planned to be extracted during the procedure. General anesthesia was induced with nasal intubation. Local anesthetic agent lignocaine 2% with adrenaline (1:80000) was injected in the vestibular area with relation to 41,42,31,32,33,74,36.
Crevicular incision given from 31 to 36 and vertical releasing incision given distal to 31 and 36. Mucoperiosteal flap was raised and the surgical site was exposed. Now, with the help of round bur a window was created just below the apices of lower anterior teeth. Window size was slightly increased with the help of bone nibler and cystic lining was seen [Figure 3b].
Cystic lining was separated from bone and removed completely. A decision was made to extract the primary molar and permanent tooth bud of first permanent premolar as it was involved in the cystic cavity. Irrigation was done with normal saline. Surgical site closed with help of 3.0 silk suture [Figure 3c].
Pressure dressing given extraorally over that area with help of dynaplast. Postoperative medication given and patient recalled after 7 days.
Radicular cysts originating from primary teeth are very rare and only a few cases have been published. Usually periapical radiolucencies related to primary teeth are neglected and in many cases they resolve after tooth extraction. Radicular cysts are mostly asymptomatic and are only discovered when periapical radiographs are taken. In primary teeth, pulp and inter-radicular infections have a tendency to drainage more than permanent teeth. This case was diagnosed as radicular cyst because of the presence of a large and painless radiolucent lesion in relation to the roots of a non-vital primary tooth, predominant mandibular buccal cortical plate expansion, and histological confirmation of cystic epithelial lining.
A series of radicular cysts associated with endodontically treated deciduous teeth with material containing formocresol which, in combination with tissue protein, is antigenic and has been shown to elicit a humoral and cell-mediated immune response was reported by Grundy, Adkins, and Savage. The present case reports a radicular cyst associated with primary molar which was non-endodontically treated.
Usually radicular cysts are unilocular similar to the one seen in this case. Radicular cysts arising from deciduous teeth may mimic dentigerous cyst radiographically, especially when they are multilocular. That possibility was ruled out in the present case as the lesion was associated with a grossly decayed non-vital primary molar.
Since, in the present case the first premolar was displaced, away from its normal path of eruption, with loss of its follicular space, it had high chance of being impacted; therefore, it was extracted in a similar case. Also, the tooth bud was in the cystic cavity in the present case. However, reported cases of normal alignment of the permanent teeth occurring spontaneously even though the initial positions were highly unfavorable.
Radicular cyst in deciduous dentition affects the mandibular teeth (as in this patient) because they are the ones most frequently affected by caries; in contrast, there is maxillary predominance in permanent dentition. Most authors agree that the treatment of choice is enucleation of the cyst. Marsuplization is indicated when there is no likelihood of damaging anatomic structures and a more conservative intervention. The major disadvantage of the marsupialization technique is that pathologic tissue is left in situ without thorough histologic examination and multiple visits are required for regular washing of the cavity and follow-up. In the present case enucleation was preferred, because the pathologic cavity was not large and because we wanted to get histopathological confirmation of the diagnosis.
In children, healing of the postsurgical osseous defects is always good as they have high propensity for bone regeneration. In this case, we could not notice this because the child was from a distant place and the parents expressed their inability to visit the hospital for regular follow-ups.
More awareness campaigns especially at the primary healthcare centers in order to educate the population about the requirement for early presentation of the dento-alveolar pathologies are recommended. Early diagnosis followed by prompt treatment of any infection in the oral and maxillofacial region by the contemporary protocols in primary healthcare can help to impede the need for invasive surgical treatment and also to prevent the further complication in the jaw bone or in craniofacial region which causes major health problems to patient. To conclude, we present a rare case of radicular cyst associated with deciduous molars. For prevention of adverse effects to the underlying permanent successor teeth, recognition of the potential of radicular cysts in association with deciduous dentition is important.
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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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