The term “Paradental cyst” was introduced by Craig in 1976. However, the clinical, radiological, and histological features of lesions of this kind were described earlier by reports by Hofrath in 1930. Paradental cyst is classified as inflammatory cyst in the World Health Organization’s Classification of Odontogenic Cysts. It is defined as “a cyst occurring near the cervical margin of the lateral aspect of the roots as a consequence of an inflammatory process in the periodontal pocket.” The incidence of paradental cyst is reported to be around 3%–5%, which suggests the rarity of the lesion. Paradental cysts are commonly associated with mandibular third molars and less frequently with first molars, second molars, or premolars. Paradental cyst in the maxillary anterior region is a very rare entity. A very few cases have been reported on the incidence of paradental cysts in relation to anterior teeth and maxillary teeth, in particular.
Ackerman and Craig favored the opinion of the origin of the paradental cyst from reduced enamel epithelium. They also suggested that cyst formation occurs secondary to inflammatory destruction of periodontium and alveolar bone, leading to unilateral expansion of the dental follicle. Other authors have hypothesized obstruction of pericoronal pocket, leading to fluid accumulation and thereby leading to cystic expansion.
The current case report presents a case of paradental cyst associated with maxillary anterior teeth, which was incidentally found during immediate implant placement in the region.
A 26-year-old male presented to the department of periodontics in January 2021 with loosened teeth in the maxillary anterior teeth (#12, # 11, #21, and #22) region. The patient presented with no significant medical history. The patient was asymptomatic. On clinical examination, anterior teeth presented with >50% horizontal bone loss and increased tooth mobility with anterior maxillary teeth. The presence of dental plaque, bleeding on probing, clinical attachment level, periodontal probing depth, and mobility were recorded in the periodontal chart [Figure 1]. According to the 2017 World Workshop Classification of Periodontal and Peri-Implant Diseases, the present case was diagnosed to be generalized periodontitis, Stage IV, Grade C, unstable at the time of initial examination. Further, on examination of tooth #21, interdental papillary swelling with exudation and deep periodontal pocket was noted. On panoramic radiographic examination, a diffuse ovoid radiolucency was detected at the apices of the root of #21. The lesion was extending from the apices of the root of #21, measuring approximately around 10 mm × 5 mm. Cone-beam computed tomographic examination was performed as part of treatment planning for dental implants. However, there was no characteristic findings noted in the #21 region [Figure 2]. Provisionally, it was diagnosed to be a radicular cyst. The differential diagnosis included radicular cyst and lateral periodontal cyst. Vitality test revealed normal response, which aided in ruling out the possibility of the radicular cyst.
Written informed consent was obtained from the patient before the treatment. Under local anesthesia, intrasulcular incisions were placed to reflect the mucoperiosteal flap, and extraction of teeth #12, #11, #21, and #22 was carried out with the placement of immediate implant. On extraction of #21, incidental finding of soft tissue mass attached to the apices of the tooth was noted. The apical area of the extracted socket was thoroughly debrided to remove all the granulation tissue. Three implants of 3.3 mm × 11 mm, 3.3 mm × 10 mm, and 3.3 mm × 10 mm (Bioline Dental GmbH and Co. KG, Berlin, Germany) were placed in the anterior region of #13, #11, and #22, respectively. After extraction of #21 tooth and debridement, the socket was augmented with Cerabone® (Botiss biomaterials GmbH, Zossen Germany) and sutured using Centisorb 4.0, 3/8, reverse cutting resorbable sutures (Centenial Surgical Suture Ltd, Thane, India) to attain tension-free closure of the mucoperiosteal flap.
The tissue section on hematoxylin and eosin staining showed subepithelial connective tissue stroma continuous with cystic wall. The cystic lumen was lined by discontinuous nonkeratinized stratified squamous epithelium exhibiting hyperplasia and arcading pattern. The underlying connective tissue wall was predominantly cellular with severe inflammatory cell infiltrate. Focal areas of hemorrhage, degeneration, and microbial colonies were also evident [Figure 3]. Based on the histopathological presentation, lateral periodontal cyst was ruled out as it exhibits thin, nonkeratinized epithelium usually 1–5 cell layers thick, whereas paradental cyst is characterized by hyperplastic nonkeratinized, stratified squamous epithelium. Finally, a diagnosis of paradental cyst was made based on clinical, histopathological, and radiographic findings.
The patient was monitored weekly for the first 2 months and every once a month for the next 10 months. Radiographs were taken periodically at 3rd month and 6th month to check for any recurrence [Figure 2]. Periodontal status was assessed at 6 months and found to be satisfactory [Figure 4]. The patient is monitored clinically and radiographically for a minimum of 5 years.
The current case report presents a rare occurrence of paradental cyst in relation to maxillary left central incisor. Previous reports have noted that paradental cysts showed a male predilection. The current report aligns with sex predilection given in the literature. With regard to the site of occurrence, the lesion noted in the current report is similar to a previous report by Vedtofte and Holmstrup, who reported eight cases of inflammatory paradental cyst in the globulomaxillary area.
Paradental cysts are usually asymptomatic and may present with swelling and are detected by chance. As per previous studies, there appears to be link between periodontal pocket and cystic lumen. In the current case, the associated teeth were severely periodontally compromised. In addition, teeth associated with paradental cyst are found to be vital and show divergent roots. These findings are in consistent with the current case.
Histologically, features of paradental cyst resembles to that of radicular cyst. In the present report, arcading pattern of nonkeratinized stratified squamous epithelium, which is a classic feature seen in radicular cysts, was noted on cystic lining. However, there was no evidence of any carious involvement of tooth, and since tooth was noted to be vital, chances of lesion being radicular cyst were eliminated. Pulp vitality test is a key factor in differential diagnosis of these lesions, as they present similar features in histopathological examination. Paradental cyst and lateral periodontal cyst can be differentiated with histopathological examination as they differ mainly in terms of epithelial lining pattern. Previous authors have considered periostitis ossificans and dentigerous cyst in differential diagnosis because paradental cyst mimicking those lesions is reported in the literature. Surgical removal or enucleation and maintenance of the associated tooth are the treatment of choice. Chances of spontaneous drainage leading to regression of the lesion and healing are reported. Recurrences of paradental cysts have not been reported.
Recent findings suggest that immediate implant placement in infected socket sites is not associated with inferior implant survival rates or increased risks compared to noninfected sites. However, thorough debridement and decontamination of hard and soft tissues and removal of microbial debris are prerequisites for successful immediate implant placement. It is suggested that laser can be used for debridement of extraction sockets during immediate implant placement. The present case awakens the practitioners to be cautious regarding long-standing periodontal and periapical pathologies, which may interfere in treatment outcomes of immediate implant placement. Although cases of recurrences and associated risks have not been reported in the literature, periodic assessment and monitoring may be advised.
Paradental cyst associated with maxillary teeth is a very rare entity. Diagnosis of paradental cysts requires correlation of clinical, radiological, and histopathological findings as they closely resemble other lesions such as radicular cyst. Relying entirely on radiographic diagnosis may be a pitfall. When immediate implant placement is being planned, considerations to the periodontal and periapical diseases status of the teeth being extracted are crucial to achieve better treatment outcomes.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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