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 Table of Contents  
Year : 2020  |  Volume : 15  |  Issue : 1  |  Page : 123-126

Bilateral radicular cyst of mandible-mimicking odontogenic keratocyst treated using alloplastic calcium phosphate bone cement: An unusual case report

Department of Oral and Maxillofacial Surgery, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India

Date of Submission15-Feb-2020
Date of Decision25-Feb-2020
Date of Acceptance22-Mar-2020
Date of Web Publication13-Oct-2020

Correspondence Address:
Dr. Saurabh Simre
DMIMS Campus, Second Floor, Raghobhaji PG Boys Hostel, Room No. 17, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha - 442 004, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_45_20

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Inflammatory dental cysts of mandible are an incessant group of osteolytic lesions arising from the odontogenic epithelium having uncharacteristic appearances. The radicular cyst is, by far, the most comprehended inflammatory jaw cyst found mostly at the apices of the tooth (periapical cyst), lateral surface of the roots (lateral radicular cyst) and remains in the jaw after the removal of the offending tooth (residual cyst). They advance sluggishly and asymptomatically unless infected. Because of this, they can extent to big dimensions. Although bilateral symmetrical representation of these cysts is rare, many times, it is baffling to segregate radicular cysts from the obligatory preexisting chronic periapical periodontitis lesions or benign asymptomatic, osteolytic neoplasms radiographically, and hence, may create a challenge for the diagnosis. Herein, we describe the case of a 45-year-old female patient who presented with pain over the right and left side of the mandible. Orthopantomogram showed large, well-defined, corticated, and unilocular radiolucencies over the bilateral molar region. Fine-needle aspiration cytology was performed, and the patient was treated with beta-lactam antibiotics trailed by surgical enucleation of cystic sac, extraction of the transgressing tooth, and rehabilitation using the alloplastic graft as bone void filler. The patient responded well to prompt systemic antibiotics and local surgical measures with a complete resolution of the infection and spontaneous bone regeneration.

Keywords: Alloplastic bone graft, bilateral mandibular radicular cysts, biocomposite, bone stimulants, calcium phosphate, enucleation, mimicking lesions, odontogenic inflammatory cysts, odontogenic keratocyst, osteoconduction, radicular cyst

How to cite this article:
Simre S, Patil C, Jadhav A, Kambala R. Bilateral radicular cyst of mandible-mimicking odontogenic keratocyst treated using alloplastic calcium phosphate bone cement: An unusual case report. J Datta Meghe Inst Med Sci Univ 2020;15:123-6

How to cite this URL:
Simre S, Patil C, Jadhav A, Kambala R. Bilateral radicular cyst of mandible-mimicking odontogenic keratocyst treated using alloplastic calcium phosphate bone cement: An unusual case report. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2020 Oct 28];15:123-6. Available from: http://www.journaldmims.com/text.asp?2020/15/1/123/297987

  Introduction Top

Jawbones are host to diverse odontogenic and nonodontogenic cysts and neoplasms. Cysts of the jaws, both odontogenic and nonodontogenic, can exhibit a biologically aggressive behavior and often pose a diagnostic challenge. Cysts can present as functional disturbances caused by the bone remodeling and abating or after a secondary infection.[1]

The inflammatory cysts are lesions that originate from the infection of root canals from caries or occurrence of a trauma that procured pulp changes. The appearance of these cysts occurs from the preexistence of a periapical granuloma or by the induction of epithelial rests of Malassez.[2] Radicular cysts are utmost collective inflammatory cysts developing from the epithelial deposits in the periodontal space or following pulpal necrosis. The lesion is not clinically detectable when it is small, but most often is discovered as incidental finding on the radiographic examination. Differentiating radicular cysts from other lesions could be challenging if the clinical presentation and radiographic appearance are unusual, thereby making the differential diagnosis important. The aggressive osteolytic lesion may imitate benign neoplasm or other developmental cysts that may pose a diagnostic dilemma to the clinician. This case report intends to show a dual purpose of certifying outsized, bilateral radicular cysts of the mandible, which is rare in literature; second, it implies the importance of mimicking lesions which can severely change our treatment planning.

  Case Report Top

A 45-year-old female presented with a complaint of pain over the bilateral buccal gingiva circumscribing premolar-molar region for 3 months approximately. She reported of a pricking intermittent type pain on mastication in the same region, associated with fever 2 months earlier. The patient consulted local dentist, who prescribed her antibiotics and analgesic medications which proved to be ineffective.

The patient had no other associated symptoms other than pain. Clinically, the patient revealed grossly decayed mandibular molar teeth on both sides which were tender on percussion with obliteration of the buccal vestibule on the left side [Figure 1]. The orthopantomogram (OPG) showed bilateral, well-defined, ovoid radiolucencies surrounded by a sclerotic margin near the apices of the mandibular molar region. Both radiolucencies were about 20–25 mm wide along with root resorption. The radiolucencies extended anteroposteriorly along the body of the mandible [Figure 1]. Fine-needle aspiration revealed muddy-colored serous fluid, which was sent for cytological examination. Cytology report was suggestive of infected dental cyst.
Figure 1: (a) Preoperative orthopantomography presenting well-defined radiolucent lesions with sclerotic borders over the bilateral mandibular molar region (arrows). (b) Preoperative intraoral photograph presenting obliteration of the buccal vestibule

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Before cystic enucleation, all nonvital teeth were subjected to endodontic treatment. Electric and thermal pulp-vitality test was performed for all the mandibular teeth, and 47, 46, 45, 44, 34, 35, 36, and 37 were recorded to be nonvital. Under all aseptic conditions, root canal therapy was performed under local anesthesia (2% lignocaine with adrenaline). Conventional access opening of the tooth followed by biomechanical preparation using the Protaper NiTi rotary system was done. Intracanal irrigant and medicaments used were 3% of sodium hypochlorite and 2% chlorhexidine, respectively. Obturation was completed using the lateral condensation technique. Finally, all the root canals-treated teeth were restored using glass-ionomer cement.

Empirical therapy of amoxycillin + clavulanic acid 1.2 g intravenous was prescribed, and the patient was planned for enucleation of the bilateral cystic lesion with offending tooth extraction, open debridement, curettage, saucerization, and peripheral ostectomy along with chemical cauterization using Carnoy's solution. Thorough cystic lesion was enucleated without breaking the continuity [Figure 2]. Curettage, saucerization, and chemical cauterization were performed preserving the inferior alveolar nerve. The bony cavity defect was packed with calcium phosphate bone cement + injection gentamycin 200 mg mixed in a sterile condition rendering the cavity to an antiseptic agent. The mixture was made into a paste and derived into pellet form to be stuffed inside the cavity creating a scaffold on which bone formation can take place through osteoconductive property [Figure 2]. The curetted cystic lining was subjected for histological examination that ascertained it to be an radicular cyst.
Figure 2:(a) Intraoperative clinical view depicting complete enucleation, deep curettage, and debridement with chemical cauterization on the bilateral mandibular body region along with the preservation of the inferior alveolar nerve (arrows). (b) Final stage after the placement of alloplastic bone graft granules and sealing of the bone cavity using calcium phosphate bone cement (arrows)

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Based on the radiographic findings, the differential diagnosis of multiple odontogenic keratocyst (OKC), bilateral central giant-cell granuloma, Brown's tumor associated with hyperparathyroidism, and unicystic ameloblastoma was considered.

No postoperative complications followed the procedure. The patient was discharged on the 7th postoperative day and further reviewed monthly for clinical and radiographic assessment for a period of 6 months. The surgical site showed significant healing with adequate bone formation over osseous defect and continued well without any signs of infectious relapse or recurrent tendency [Figure 3].
Figure 3:(a) Follow-up radiograph after 3 months showing the resolution of infection and neobone formation (arrows). (b) Immediate postoperative intraoral view

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  Discussion Top

In 1974, Kramer defined a “Cyst” as a pathological-lined cavity filled with fluid, semifluid, or gaseous contents but not pus. In the present case, the large size of the cyst posed to be a potential misdiagnosis of OKC, and hence, it was confused for the final diagnosis.

As already mentioned above, the odontogenic inflammatory cysts are the lesions that rely on infectious foci from endodontic, periodontal, or pericoronal gateway of low virulence, longing for weeks to proliferate. They grow slowly from the remaining epithelial Malassez or a preexisting periapical granulomas. The nidus for the spread of infection may be a necrotic pulp or periodontal pocket.[2],[3] Radicular cyst commonly occurs in the mandible between the third and fifth decades of life, frequently occurring in females. They tend to be slow-growing, asymptomatic lesion that can be determined capriciously on OPGs as in our case. A radicular cyst to be conclusive enough to diagnose requires its existence accompanying a nonvital pulp and/or presence of a sinus tract in its vicinity.

Radicular cysts appear as round or pear-shaped unilocular radiolucent lesions surrounded by a thin radiopaque margin, extending from the lamina dura of the involved tooth and may displace adjacent teeth or cause mild root resorption. A lesion larger than 2 cm is more likely to be a cyst than a granuloma.[4]

Nearly, all radicular cysts are lined completely or in the fragment by nonkeratinized stratified squamous epithelium. The lining may be, intermittent in quantity and varies in depth from 1 to 50 cell strata. The preponderance is between 6 and 20 cell stratum thick. The epithelial linings could be thriving and arcading with a severe connected inflammatory progression or are sluggish and moderately methodical with a certain mark of differentiation. The inflammatory cell penetrates in the thriving epithelial linings comprising largely of polymorphonuclear leukocytes. Whereas adjoining fibrous capsule is penetrated principally by enduring inflammatory cells. It is quite unusual to see this lesion in a bilaterally symmetric fashion, as was seen in our case.

Osteoconductive carriers such as hydroxyapatite or tricalcium phosphate and further when these composites are combined with fresh blood, act as an osteoinductive material.[5] Calcium phosphate bone stimulant is an osteoconductive material, which rapidly integrates into the bone structure and transforms into new bone by the action of multinucleated giant cells and mesenchymal stem cells responsible for the local bone remodeling.[6] However, in spite of these good properties, it has limitations due to its slow biodegradation. More the amount of calcium phosphate used, more time it will take to heal the bony cavity. We modified its application by reducing its quantity, and only little amount were used to seal the cavity and to support overlying mucosa. Alone endodontic treatment is unlikely to resolve the factors that sustain the posttherapeutic periapical lesion. Therefore, combined approach of endodontist and surgery is indicated for the successful treatment and complete eradication of such cases.[7],[8],[9],[10]

  Conclusion Top

OKC should be deliberated as a differential diagnosis in circumstances of large, aggressive osteolytic lesions of the jaw. Prompt diagnosis and treatment ensure for better outcomes. Close follow-up is critical in determining the track of the successful treatment.

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.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Cakir BD, Subramaniam RM, Reddy SM, Imsande H, Gohel A, Sakai O. Cystic and cystic-appearing lesions of the mandible: Review. AJR Am J Roentgenol 2011;196:WS66-77.  Back to cited text no. 1
Cedin AC, de Paula FA Jr., Landim ER, da Silva FL, de Oliveira LF, Sotter AC. Endoscopic treatment of odontogenic cyst with intra-sinusal extension. Braz J Otorhinolaryngol 2005;71:392-5.  Back to cited text no. 2
de Moraes AP, Rodrigues BS. Cistos odontogênicos inflamatórios: revisão de literatura. Revista da Graduação 2011;4.  Back to cited text no. 3
Shear M, Speight PM. Cysts of the Oral and Maxillofacial Regions. 4th ed. Oxford: Blackwell; 2007. p. 123-41.  Back to cited text no. 4
Pandey V, Upadhyaya VS, Berwal V. Evaluation of G bone (hydroxyapatite) and G-Graft (hydroxyapatite with collagen) as bone graft material in mandibular III molar extraction. J Clin Diagn Res 2015;9:ZC48-52.  Back to cited text no. 5
Hirata M, Murata H, Takeshita H, Sakabe T, Tsuji Y, Kubo T. Use of purified beta-tricalcium phosphate for filling defects after curettage of benign bone tumours. Int Orthop 2006;30:510-3.  Back to cited text no. 6
Lin LM, Ricucci D, Lin J, Rosenberg PA. Nonsurgical root canal therapy of large cyst-like inflammatory periapical lesions and inflammatory apical cysts. J Endod 2009;35:607-15.  Back to cited text no. 7
Bohra S, Bhede R, Saraf S, Hande A. Radicular cyst or odontogenic keratocyst?: A case report. IOSR J Dent Med Sci 2014;13:53-7.  Back to cited text no. 8
Dhote VS, Thosar NR, Baliga SM, Dharnadhikari P, Bhatiya P, Fulzele P. Surgical Management of Large Radicular Cyst Associated with Mandibular Deciduous Molar Using Platelet-Rich Fibrin Augmentation: A Rare Case Report. Contemp Clin Dent 2017;8:647-9. Available from: https://doi.org/10.4103/ccd.ccd_370_17. [Last accessed on 2020 Jan 18].  Back to cited text no. 9
Gupta R, Chaudhary M, Patil S, Fating C, Hande A, Suryawanshi H. Expression of P63 in Tooth Germ, Dentigerous Cyst and Ameloblastoma. J Oral Maxillofac Pathol 2019;23:43-8. Available from: https://doi.org/10.4103/jomfp.JOMFP_125_18. [Last accessed on 2020 Jan 18].  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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