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 Table of Contents  
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 26-29

Radicular cyst of the anterior maxilla: An insight into the most common inflammatory cyst of the jaws

1 Department of Oral Medicine and Radiology, Dhulikhel Hospital, Nepal
2 Department of Oral and Maxillofacial Surgery, Dhulikhel Hospital, Nepal
3 Department of Oral Pathology, Penang International Dental College, Malaysia
4 Department of Oral Pathology, Dhulikhel Hospital, Nepal

Date of Web Publication23-Apr-2019

Correspondence Address:
Sushmit Koju
Department of Oral Medicine and Radiology, Dhulikhel Hospital, Dhulikhel-45210, Kavre
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_64_18

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Radicular cyst is believed to be derived from the epithelial cell rests of Malassez. The associated tooth is nonvital, usually asymptomatic, and may result in swelling, tenderness, tooth mobility, or other problems with rare possibility of neoplastic transformation of its epithelial lining. The treatment options include endodontic procedure, extraction of offending tooth, enucleation with primary closure, and marsupialization. The present report describes the case of a radicular cyst of anterior maxillary region in a 31-year-old male patient, with a detailed description of clinical, radiographic, histopathologic features, pathogenesis, and its surgical management.

Keywords: Enucleation, maxilla, pathogenesis, radicular cyst

How to cite this article:
Koju S, Chaurasia NK, Marla V, Niroula D, Poudel P. Radicular cyst of the anterior maxilla: An insight into the most common inflammatory cyst of the jaws. J Dent Res Rev 2019;6:26-9

How to cite this URL:
Koju S, Chaurasia NK, Marla V, Niroula D, Poudel P. Radicular cyst of the anterior maxilla: An insight into the most common inflammatory cyst of the jaws. J Dent Res Rev [serial online] 2019 [cited 2023 Apr 2];6:26-9. Available from: https://www.jdrr.org/text.asp?2019/6/1/26/256809

  Introduction Top

The radicular cyst is the most common inflammatory cyst in the jaw that is of odontogenic origin.[1] The cyst is believed to be originated from the epithelial cell rests of Malassez.[2] It is usually associated with a tooth having a necrozed pulp. The lesion is seen mostly in the males during their third and fifth decades of life.[3] Treatment of radicular cyst depends on the size of the lesion and can be treated with a simple conventional therapy or may require a surgical intervention.[4] The present report deals with the literature review of all the aspects of the radicular cyst with an emphasis on its pathogenesis.

  Case Report Top

A 31-year-old male patient presented to the Department of Oral Medicine and Radiology, with the chief complaint of discoloration of the upper front tooth for 4 years. The patient recalled a history of trauma in the offending tooth 4 years back. Although the tooth was asymptomatic, it started to develop blackish discoloration. Endodontic treatment was done 3 months back; however, he failed to rehabilitate the tooth with prosthetic crown. His past medical history was non-contributory.

Intraoral examination revealed discoloration in relation to tooth number 11 [FDI] with clinically healthy appearing periodontium. The tooth 11 showed no signs of mobility and was nontender to pressure and percussion. The patient was advised for intraoral periapical radiograph, anterior occlusal, and panoramic radiograph for radiological evaluation.

Radiographs [Figure 1] revealed a well-defined horizontal radiolucency at the incisal-third of the crown with reduced overall height of the crown, suggestive of attrition. There was a homogenous radiopacity involving the entire pulp chamber and the canal, suggestive of prior endodontic treatment. The radicular and the periodontal ligament (PDL) portion appeared radiographically normal. The lamina dura was obliterated at the apical third of the root. There was a well-defined radiolucency at the periapical region with respect to 11 of size approximately 1.25 cm × 1 cm with cortical margin; its epicenter lying 5 mm apical to the root apex. There was no evidence of root resorption/displacement of the adjacent tooth. The radiographic findings were suggestive of periapical cyst.
Figure 1: Intraoral periapical radiograph and maxillary anterior occlusal radiograph showing the lesion

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Surgical enucleation was done under local anesthesia after obtaining an informed consent from the patient. The operating site was anesthetized with 2% lignocaine containing 1:100,000 adrenaline. Sulcular incision from the region of 13–21 was given. Then, a vertical incision mesial to 13 and distal to 21 was given, and a trapezoidal mucoperiosteal flap was raised. The overlying thinned bone was removed with bur under copious irrigation to expose the cystic mass. During the procedure, the cyst was found to be infected with the evidence of pus discharge from the cyst. The cyst was enucleated, and thorough curettage was done. Flap closure was done with 3–0 silk suture, and the specimen was sent for histopathological examination [Figure 2].
Figure 2: Intra- and post-operative procedures

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Histopathological examination revealed a cystic cavity lined by nonkeratinized stratified squamous epithelium arranged in an arcading pattern, interspersed with intense inflammatory cell infiltration consisting chiefly of lymphocytes and plasma cells. Russel's bodies were also noted at places. The histopathological findings confirmed the diagnosis of radicular cyst [Figure 3].
Figure 3: Histopathological picture (a) nonkeratinized squamous epithelium with arcading pattern (×10) (b) red arrows showing Russell bodies (×100)

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  Discussion Top

Periapical cysts are inflammatory jaw cysts that appear at the apices of infected teeth with necrotic pulps. Based on the opening or connection of the root canal to the epithelial-lined cavity, periapical cyst were categorized into bay cyst or apical cyst.[2] The cystic cavity with epithelial linings that are open to the root canal is considered as a bay cyst, which is now termed as “periapical pocket cysts” due to its similarities with the marginal periodontal pocket,[2] whereas a cystic cavity with complete epithelialization but no opening into the apical foramen and root canal is regarded as apical cyst. At present, it is referred to as radicular cyst/true cyst. Sometimes, the cyst may appear on the lateral aspect of the root when the lesion is associated with lateral accessory root canals.[5] Among all the jaw cysts, radicular cysts make up about 52%–68%.[4]

It involves both the primary and permanent dentition with a range of 0.5%–3.3%. They are more common in males compared to females with a ratio of 1.6:1. Females are more concerned about their teeth, which might be a reason for lower frequency of the lesion in females.[2]

The anterior maxilla is more common as compared to the mandible. The involvement of anterior maxilla may be due to trauma, caries, and old silicate restorations in the anterior teeth.[6] In our case, trauma was the cause behind the development of the lesion. There are various opinions put forward for explaining the formation of this cyst. Torabinejad (1983) described the pathogenesis of radicular cyst according to the “breakdown/nutritional deficiency theory” and “abscess cavity theory.” The “breakdown” theory suggests that after provocation, the epithelial cells continue to proliferate following which the central cells become deprived of nutrition from the surrounding connective tissue and undergo liquefactive necrosis, leading to the development of a microscopic cyst. According to the “abscess cavity” theory, the epithelial cells proliferate and line a preexisting cavity (abscess) because of their inherent tendency to cover exposed connective tissue surfaces. This theory was also supported by Mcconnell.[7] Another hypothesis suggested that the cyst formation was due to a direct result of epithelial proliferation around a space caused by proteolytic activity occurring in the connective tissue.[2] However, the most accepted theory is the epithelial breakdown theory as also supported by previous articles.[2],[7] The pathogenesis of radicular cysts can be further described under three distinct phases, namely, the phase of initiation, the phase of cyst formation, and the phase of enlargement [Figure 4].[8]
Figure 4: Pathogenesis of Radicular cyst (a) carious tooth showing a periapical infection (b) phase of initiation (c) phase of proliferation (d) phase of cyst formation (e) nonvital tooth with a radicular cyst

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Initially, the epithelial cell rests of Malassez in the PDL are stimulated to proliferate as a result of trauma or infection [Figure 4]b. Next, a cavity is formed by the liquefactive necrosis of odontogenic epithelium [Figure 4]c. The third phase (enlargement) has been the focus of considerable experimental work [Figure 4]d. Studies in the past have provided evidence for the hypothesis that osmosis has a role to play toward cyst enlargement. The lytic products of the epithelial and inflammatory cells make a contribution to the change in osmotic pressure in different areas, leading to increase in the size of cysts.[2] The size of a radicular cyst on an average can range from 0.5 to 1.5 cm in size. A rare case reported a 5 cm × 3.5 cm intraosseous radiolucent lesion diagnosed as radicular cyst.[9]

The different phase of the pathogenesis of radicular cyst may also be described in relation to the different molecular interactions. The phase of initiation has been linked to the role of various cytokines and chemokines [Figure 4]b. The infection from the caries spreads into the periapical area, where the bacterial endotoxins trigger the epithelial cell rests to multiply. As a result, an inflammatory process occurs, resulting in the release of cytokines.[10],[11]

The chemokines such as Regulated upon Activation, Normal T-cell Expressed, and Secreted, interferon gamma-induced protein, and monocyte chemoattractant protein are frequently encountered in the radicular cysts and have thought to have a role in the pathogenesis of the cyst formation.[12] In addition, the secretion of vascular endothelial growth factor (an angiogenic growth factor) has been identified, which seems to increase the vascular permeability, leading to expansion of the cyst.[13] Bone-resorbing factors such as receptor activator of nuclear factor kappa-B ligand and osteoprotegerins have been expressed in radicular cyst, which could have a role in facilitating the cystic expansion.[13] The osteoclastic bone resorption may be increased by a wide range of biologically active molecules.[14]

Clinically, the teeth affected with radicular cyst are asymptomatic. Radicular cyst may present as a swelling of the jaw and may be associated with pain/loosening of tooth. Root resorption of the affected tooth and displacement of the adjacent teeth have also been observed.[15]

The cystic fluid plays an important role in the diagnosis of odontogenic cysts. The cystic content may vary from a clear, yellow-colored fluid to a solid cheese-shaped lump. Total protein content is usually between 5 and 11 g/100 ml. This is greater in comparison to the protein contents of other odontogenic cysts such as odontogenic keratocyst and dentigerous cyst.[16] The concentration of globulin (both α1 and β) has been observed to be higher than that observed in other odontogenic cysts.[16]

Histologically, the cystic cavity is lined by nonkeratinized stratified squamous epithelium, which may be discontinuous, especially in areas of intense inflammatory cell infiltration. In the early stages, cells of the epithelial lining may be proliferative and show arcading pattern with intense chronic inflammatory infiltrate. Rarely, mucous-producing cells may be observed within the epithelial lining. The presence of these mucous cells is thought to be due to metaplastic transformation of the squamous cells. This particular finding was observed in the current case as well. The underlying connective tissue wall is usually mature and collagenous and is infiltrated by chronic inflammatory cells; predominantly composed of lymphocytes and plasma cells. The lumen of the cyst usually contains a fluid with varying concentration of protein and may contain a great deal of cholesterol. In rare instances, limited amounts of keratin may also be found.[17]

Rushton bodies (hyaline) are observed occasionally, and these are described as cuticular or keratin-like products of odontogenic epithelium. These form as a result of entrapment of blood vessels within the epithelium, resulting in vascular thrombosis. Another hypothesis suggests that they are secretions of stimulated epithelial cells that later undergo calcification.[18] It may also form due to elastotic degeneration or as a product of cellular reaction to extravasated serum.[19]

Cholesterol crystals in paraffin sections are dissolved by the fat solvents during tissue processing, leaving a needle-shaped cleft known as “cholesterol clefts” within capsular stroma.[20]

The cholesterol cleft is actually formed as a result of degeneration and disintegration of epithelial cells, which later get accumulated in the stroma.[21] However, another school of thought suggests that cholesterol is derived from the circulating plasma lipids.[20] Finally, according to Browne RM, the main source of cholesterol crystals is the disintegration products of hemolysis.[19]

Another feature, that is, commonly encountered in the histopathology of radicular cysts are described as Russell bodies. Initially, Russel bodies were thought to be degenerated plasma cells that were persisting in the stroma.[22] Later, Jordan and Speidel suggested that these bodies were nothing but hemocytoblasts, which failed to undergo normal transformation.[22] Further, Michaels suggested that these are actually red blood corpuscles, which had been engulfed by the plasma cells.[22]

The treatment of the radicular cyst depends on the size and localization of the lesion.[23] It can be treated with endodontic therapy, extraction, surgical procedure such as enucleation, and marsupialization.[3] In our case, the treatment of choice was surgical enucleation and curettage. One of the complications associated with a poor prognosis of radicular cyst is the occurrence of malignant transformation of the lining epithelial cells. One report in the literature describes the formation of squamous odontogenic tumor-like proliferations within the lining of radicular cysts.[23]

These occurrences have been observed in around 3.4% of the cases studied. Radicular cyst of the maxillary region was the most common site, showing such transformation.[24] Therefore, the treatment of radicular cysts should be prompt to avoid any potential complications.

  Conclusion Top

Radicular cyst is one of the common lesions encountered in dental practice. The pathogenesis of cyst formation is a complex process involving a wide range of biologically active molecules and their interactions. In this article, we have tried to illustrate the pathogenesis of cyst formation and also the various clinical and diagnostic features. Since there are chances of neoplastic transformation within the epithelial lining of a radicular cyst, proper treatment and a long-term follow-up are recommended.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Nair PN. New perspectives on radicular cysts: Do they heal? Int Endod J 1998;31:155-60.  Back to cited text no. 2
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Ramachandran Nair PN. Non-microbial etiology: Periapical cysts sustain post-treatment apical periodontitis. Endod Top 2003;6:96-113.  Back to cited text no. 5
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de Moraes M, de Matos FR, de Souza LB, de Almeida Freitas R, de Lisboa Lopes Costa A. Immunoexpression of RANK, RANKL, OPG, VEGF, and vWF in radicular and dentigerous cysts. J Oral Pathol Med 2013;42:468-73.  Back to cited text no. 13
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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