The Dilemma Of Management Of Cystic Lesions; An Uncertain Way Forward: A Case Report.

Periapical diseases ranges from mild granulomatous lesions to large cystic ones, with the treatments corresponding to their respective pre-operative diagnoses. However, the determination of cause of periapical radiolucency is impossible on pre-operative clinical and radiographic examinations. We present a case highlighting the difficulties encountered in treating a periapical cyst using the current evidence in literature. It demonstrates the uncertainty involved in treating such lesions, owing to the impossible nature of determining the histopathological nature of the cyst, i.e., being either true cysts or pocket cysts. This case includes orthograde re-treatment; decompression of the cystic lesion, followed by peri-apical surgery of two teeth over a course of three years; and the uncertain outcomes encountered after each phase of the treatment.

Platelet-rich fibrin combined with synthetic nanocrystalline hydroxy apatite granules in the management of radicular cyst.

Radicular cysts are inflammatory jaw cysts confined to the apices of teeth with infected and necrotic pulp. They arise from the epithelial residues in the periodontal ligament as a result of inflammation, following the death of pulp. The treatment of such lesions vary with regard to their sizes; the small cystic lesions heal after an endodontic therapy, but larger lesions, may require additional treatment. Apical surgery for radicular cysts generally involves apical root resection and sealing with endodontic material. This case report, describes the treatment of a cyst related to the maxillary central and lateral incisors using platelet rich fibrin along with synthetic nanocrystalline hydroxyapatite granules for the regeneration of lost tissues. A follow-up evaluation at 6 months and 1-year revealed a significant radiographic bone fill with satisfactory healing at the surgical site.

[Complex treatment of a large radicular cyst in the anterior region of the maxilla. Case report]. / A maxilla front régiójában elhelyezkedo nagy kiterjedésu radikuláris ciszta komplex ellátása. Esetismertetés.

As opposed to other odontogenic cysts, the radicular cyst is always produced by intraradicular infection, therefore it is important to eliminate the cause of the inflammation as well. During the healing of the radicular cyst, the infected tooth should be treated by extraction or root canal treatment completed by surgical intervention. The presented case is a 77 year-old male patient with Type II Diabetes, who required oral surgery and endodontic treatment. Despite of the age and diabetes of the patient, the bone regeneration was rapid and complete. Seven months after starting the treatment, the size of the cyst decresed significantly and by 12th month it was perfectly healed.

Management of radicular cysts using platelet-rich fibrin and bioactive glass: a report of two cases.

Platelet-rich fibrin (PRF) created by Choukroun's protocol concentrates most platelets and leukocytes from a blood harvest into a single autologous fibrin biomaterial. However, no current data is available concerning the use of PRF for the treatment of periapical lesions. Two cases of radicular cysts were reported using an interdisciplinary approach, including regular endodontic therapy followed by surgical management with PRF and bioactive glass. Two cases of radicular cysts presented as an incidental radiographic finding, appearing as an apical radiolucency with well-circumscribed sclerotic borders. After regular endodontic retreatment, cystic lining/granulation tissues were enucleated and the periradicular bony defect was grafted using PRF and bioactive glass. Then, PRF was applied to serve as a membrane over the grafted defects. Recall periapical radiographs of Case 1 and cone beam computer tomography of Case 2 showed satisfactory healing of the periapical pathosis. In Case 2, the bony defect appeared completely healed at 4 months surgical reentry and the new bone was clinically very dense and mature. The results of these case reports show that the combination of PRF and bioactive glass is an effective modality of regenerative treatment for radicular cysts.

Treatment options of periapical cysts of deciduous teeth: report of a case and systematic review of the literature.

AIM: Periapical cysts of primary teeth are pathologic entities which are seldom encountered in the clinical practice. Most frequently, these lesions arise in correspondence with primary teeth presenting previous pulp therapy, severe carious lesions, or a history of previous trauma. The aim of the present study is to systematically review the treatment modalities of periapical cysts of the deciduous, along with the reporting of a clinical case. MATERIALS: A case of periapical cyst treated with marsupialization occurring in an 11-year-old patient is described. A literature search was devised to retrieve studies reporting the treatment of periapical cysts, and involved papers published in the Cochrane Oral Health Group specialist trials, MEDLINE via PubMed, and EMBASE up to March 2023. A total of 39 articles were retrieved. Following title and abstract analysis, 27 articles were selected for full-text analysis, with the final inclusion of 24 articles. CONCLUSION: Periapical cysts of primary teeth present an overall good prognosis irrespective of the treatment option adopted. The performance of a prompt diagnosis appears of utmost importance, as the extraction of the primary teeth involved implies the management of the residual space for the correct positioning of the corresponding permanent teeth.

Nonsurgical management of large periapical lesion in mature and immature teeth using different calcium hydroxide formulations: case series.

This case series evaluates the effectiveness of different calcium hydroxide formulations with various vehicles in management of large periapical lesion in mature and immature teeth. This will help clinicians to make informed judgments about which formulations of calcium hydroxide should be used for specific endodontic procedures.

Cystic lesions of the jaws - a clinicopathological study of 322 cases and review of the literature.

Three hundred and twenty-two patients (192 male and 130 female) with cystic lesions of the jaw were successfully diagnosed and treated. One hundred and fifty-five (48%) were radicular cysts, 80 (25%) were dentigerous cysts, 23 (7%) were odontogenic keratocyst (=keratocystic odontogenic tumor), 19 (6%) were eruption cysts, 16 (5%) were traumatic bone cysts, and 29 (9%) were non-odontogenic cysts. There were 95 in the pediatric age group (1 month to 16 years) and 227 in the adult age group (17 years and older). Male to female ratio was 1 in the pediatric age group and 1.7 in the adult age group. The treatment modalities were: marsupialization, enucleation, enucleation with bone grafting, or resection. The distribution and characteristics of jaw cysts in children are different from those in adults. In children there is a relatively high rate of developmental cysts, whereas in adults the inflammatory cysts are more common. Following enucleation of a cystic jaw lesion, the entire surgical specimen and not only a biopsy specimen, should be examined histopathologically to prevent any possibility of an intramural squamous cell carcinoma that may be overlooked. The differences in prevalence of each type of jaw cyst during a lifetime may point toward a multifactorial polygenic pattern rather than a monogenic pattern.

Management of large periapical cystic lesion by aspiration and nonsurgical endodontic therapy using calcium hydroxide paste.

AIM: To report a case of conservative nonsurgical management of periapical lesions. BACKGROUND: Small periapical lesions of endodontic origin usually heal by conventional endodontic therapy alone. Larger periapical lesions presumed to be cystic may require additional treatment protocols to aid in regression. Conservative nonsurgical management of such lesions eliminates the possible complications of surgery and has wider patient compliance and acceptance. CASE DESCRIPTION: A periapical cystic lesion associated with maxillary central incisor and lateral incisor was treated conservatively using buccal aspiration decompression followed by conventional endodontic therapy employing calcium hydroxide iodoform paste as intracanal medicament is reported. CLINICAL SIGNIFICANCE: The treatment was successful as evidenced by relief of symptoms and radiographic evaluation. CONCLUSION: Large periapical cyst-like lesions can resolve by nonsurgical endodontic therapy employing calcium hydroxide intracanal interappointment medicament.

Can traumatic occlusion cause endodontic problems? A case report.

Radicular cysts are commonly found odontogenic cysts in the jaws. The lesion is diagnosed mainly in young patients during the second decade of life. In the majority of cases, it is asymptomatic. This paper reports a rare case in which traumatic occlusion was identified as the etiology of a radicular cyst. Endodontic treatment was performed and the traumatic occlusion also was corrected. A six-month follow-up appointment found good healing of the periapical region.

Rehabilitation of a cystic mixed dentition mandible following marsupialization with a multipurpose acrylic splint acting as a space maintainer and an obturator.

Radicular cysts are the most common odontogenic cystic lesions of inflammatory origin which can be managed by marsupialisation specially if the cyst is large and is in relation to the vital structures. This article presents a case in which a radicular cyst was present in association with grossly carious deciduous molars and has been treated by marsupialisation. Postoperatively a surgical splint was inserted to maintain the patency of the bone cavity. This obturator splint also acts as a space maintainer to prevent space loss and ensure unimpeded eruption of permanent premolars.

An unsuspected ameloblastoma in the subpontic region of the mandible with consideration of pathogenesis from the radiographic course.

The purpose of this report is to document a case of unsuspected ameloblastoma involving the right man dibular subpontic region in a 38-year-old Cambodian female patient. This lesion was purportedly preceded by multiple radiolucencies which were diagnosed as radicular cysts and treated a few times in the past years by enucleation followed by endodontic therapy of the affected teeth. Bridgework restoration of the partially edentulous area was performed. This case report demonstrates radiographic changes that occurred in the periods before and after the diagnosis of ameloblastoma. The case may represent an example of radicular cysts and ameloblastoma occurring as a collision phenomenon, or the ameloblastoma may have arisen as a result of neoplastic transformation of the lining epithelium in an inflammatory odontogenic epithelial cyst.

Radicular cyst with actinomycotic infection in an upper anterior tooth.

Actinomycosis is an infection caused by filamentous, branching, Gram-positive anaerobic bacteria. It rarely infects the jawbone. This case report describes a patient with a left maxillary central incisor with an apical lesion and actinomycotic infection. A 23-year-old male patient underwent conventional root canal treatment of tooth 21, in a local dental clinic for about 1 year. However, percussion pain and a sinus tract that originated from tooth 21 were still present after treatment. Nonsurgical root canal treatment of tooth 21 was performed again but failed to relieve the symptoms. Therefore, apicoectomy and retrograde filling of the apical root canal with mineral trioxide aggregate were carried out. Periradicular bony defect was grafted by biocompatible material, and postoperative antibiotics (250 mg amoxicillin) were given three times daily for 5 days. Pathological examination of the removed periapical tissue showed a radicular cyst with actinomycosis. At the 9-month postoperative recall, the sinus tract had disappeared and radiographic examination showed healing of the apical lesion. Periradicular actinomycosis is one important reason for failure of nonsurgical endodontic treatment. Clinically, if the tooth shows a recurrent sinus tract and poor response to conventional root canal treatment combined with antibiotic control, apical actinomycotic infection should be highly suspected, and an alternative endodontic surgical approach is needed for successful treatment.

Management of Large Radicular Lesions Using Decompression: A Case Series and Review of the Literature.

The purpose of this study was to report the clinical efficacy of decompression for 3 cases with large periapical lesions and to review technique details. Three cases with large periapical cystic lesions were treated with decompression after root canal treatment. A traditional decompression technique was used for the first case. After aspiration, mucogingival incision, irrigation, and incisional biopsy, a pediatric endotracheal tube was sutured in place and kept for 3 weeks for lesion debridement. An aspiration/irrigation technique was adopted for the second case. An 18-G needle with a syringe was used to aspirate the cystic lesion. Two needles were then inserted into the lesion; copious saline irrigation was delivered from 1 needle and until clear saline was expressed from the other. For the third case, decompression was accomplished with a surgical catheter that was subsequently replaced with a gutta-percha plug after 1 month. None of the 3 cases underwent complete enucleation and root-end surgery. Healed lesions or lesions in healing were observed after 1 to 2 years. Based on the presented cases and published case reports on decompression, a literature review was provided covering indications, technique details, modification, and prognosis of decompression in endodontics. For large periapical cystic lesions, conservative decompression may be used for certain cases before or in lieu of apical surgery. Decompression enables healing of large, persistent periapical lesions after root canal treatment.

Marsupialization of a Large Radicular Cyst with Extensive Maxillary Tooth Displacement: Eight-Year Follow-Up.

Radicular cysts arising from primary teeth are uncommon and, when present as large lesions, may adversely affect the underlying permanent teeth. The purpose of this paper is to describe the management of a very large atypical radicular cyst involving the primary dentition of a nine-year-old boy and causing extensive tooth displacement with transposition of the permanent maxillary left canine between the bicuspids. The root apex of the canine was close to the median level of the lateral border of the nasal cavity and showed incomplete root formation and signs of dilacerations in its apical third. Marsupialization was successfully performed, followed by long-term orthodontic treatment. This interdisciplinary management facilitated the lesion resolution for repositioning of the canine into functional occlusion. (J Dent Child 2019;86(1):64-8)
Received October 23, 2018; Last Revision January 10, 2019; Accepted January 11, 2019.

Complete Healing of a Large Cystic Lesion Following Root Canal Treatment with Concurrent Surgical Drainage: A Case Report with 14-Year Follow-Up.

We describe complete healing of an extensive cystic lesion by using a conservative approach: root canal treatment with concurrent surgical drainage. A silicone Foley catheter drain was modified into a surgical drainage stent, which was then used for 4 weeks. Disinfection of the root canal was achieved by the use of hand files and irrigation with 5.25% NaOCl for a minimum of 30 minutes. The irrigant changes were performed at 5-minute intervals, and no intracanal dressing was used. At subsequent follow-up examinations, cone-beam computed tomography and periapical radiographs confirmed that complete healing had occurred around the periapical and lateral areas of affected teeth. This case report indicates the potential for healing of large cystic lesions by nonsurgical root canal treatment.

Favorable response of an extensive periapical lesion to root canal treatment.

This article presents non-surgical resolution of an extensive periapical lesion of endodontic origin associated with the maxillary left lateral incisor. Clinical examination revealed an asymptomatic bony hard swelling confined to the palate, while radiographic analysis showed a lesion measuring 22 mm in diameter and nearly 389 mm(2) in area. Through apical patency, 4 ml of intracanal exudate was drained. After thorough biomechanical preparation, a calcium hydroxide/CPMC root canal dressing was applied and periodically renewed for 11 months. The exudate was eliminated at treatment onset and significant bone formation was observed at the periapical region in the following months with concomitant resolution of the cortical expansion. Complete radiographic resolution of the periapical lesion was observed two years after the root canal filling. Thus, non-surgical treatment of this supposedly cystic, extensive periapical lesion provided favorable clinical and radiographic response.

[Clinical efficacy of Nd:YAG laser combined with Vitapex paste in the treatment of periapical cysts around single root].

PURPOSE: To explore the clinical efficacy of Nd:YAG laser combined with Vitapex paste in the treatment of periapical cysts around single root. METHODS: Thirty-four teeth with periapical cysts in 34 patients were treated from August 2014 to August 2016 in Taizhou People's Hospital using Nd: YAG laser, Vitapex paste was injected into the small periapical cysts, followed by conventional root canal filling. The clinical efficacy was observed every 3 months after surgery, the follow period was from 10 months to 2 years. RESULTS: Thirty four patients with 34 teeth were treated, and 32 teeth were followed up, 29 were cured, the failure rate was 6.3%. CONCLUSIONS: Nd:YAG laser combined with Vitapex paste is satisfactory in the treatment of periapical cysts around single root, which is worthy of wide clinical application.

Proliferation of epithelial cell rests, formation of apical cysts, and regression of apical cysts after periapical wound healing.

There is continuing controversy regarding the potential for inflammatory apical cysts to heal after nonsurgical endodontic therapy. Molecular cell biology may provide answers to a series of related questions. How are the epithelial cell rests of Malassez stimulated to proliferate? How are the apical cysts formed? How does the lining epithelium of apical cysts regress after endodontic therapy? Epithelial cell rests are induced to divide and proliferate by inflammatory mediators, proinflammatory cytokines, and growth factors released from host cells during periradicular inflammation. Quiescent epithelial cell rests can behave like restricted-potential stem cells if stimulated to proliferate. Formation of apical cysts is most likely caused by the merging of proliferating epithelial strands from all directions to form a three-dimensional ball mass. After endodontic therapy, epithelial cells in epithelial strands of periapical granulomas and the lining epithelium of apical cysts may stop proliferating because of a reduction in inflammatory mediators, proinflammatory cytokines, and growth factors. Epithelial cells will also regress because of activation of apoptosis or programmed cell death through deprivation of survival factors or by receiving death signals during periapical wound healing.

Conventional endodontic therapy of upper central incisor combined with cyst decompression: a case report.

Treatment of a maxillary central incisor with an associated cystic lesion by conventional endodontic therapy combined with decompression is reported. Although small cystic lesions frequently heal simply with endodontic therapy, larger lesions may need additional treatment. If surgical enucleation is elected, other teeth or structures may be damaged unnecessarily. Therefore, a case can be made for first attempting the more conservative treatment of decompression, and a workable protocol for this is presented. In this case, 6 weeks with latex tubing in place and daily irrigation with 0.12% chlorhexidine led to complete healing with no need for further surgery or other root canal therapy on teeth initially surrounded by this lesion. At the 2-year recall, the lesion has completely resolved, and the adjacent teeth remain vital and normal.