Journal of Research and Advancement in Dentistry

Surgical and Endodontic Management of large cystic lesion

Manoj Chowdhury1a, Utpal Mukherjee2

Abstract:
A large radiolucent lesion in the body of the mandible treated both surgically and endontically,
diagnosed as residual cyst. One year follow up shows complete bone regeneration with proper
healing

Introduction:
There are many odontogenic lesions which
may or may not endodontic origin but on
radiograph looks like endodontic origin.
Not only cystic lesion, but sometimes
benign odontogenic tumour like
ameloblastoma mimicking a periapical
lesion. Some cases of benign and malignant
lesions mimicking other periapical lesions
radiographically,such as odontogenic cysts,
lymphomas, periapical cemento-osseous
dysplasia, central giant cell lesions and
ameloblastomas, have been described in the
literature.1 In any large radiolucent lesion in
the jaw bones, it must be thoroughly
examined and investigated before any
treatment procedures undertaken.
Endodontic origin of periapical -cystic
lesion most of the
cases well responded by Root Canal
Treatment (RCT) only, but in few cases
require surgical intervention to complete
cure the lesion. Nowadays, our aim is to
preserve the tooth/teeth as long as possible
through modern endodontic
treatment, but sometimes we are unable to
save the offending tooth due to
aggressiveness of the lesion.A case is
presented in which large lesion in the body
of the mandible affecting two teeth (second
premolar and second molar) was treated
both surgically and endodontically.
Case Report:
A 26 year old female patient reported to
Department of Conservative Dentistry and
Endodontics with swelling of the lower left
jaw for last one month. Past dental history
revealed that # 36 was extracted three years
back due to grossly decayed, and extraction

a
was done from local dentist. At that time no
Corresponding author: dr_manoj@vsnl.net
1
Prof & HOD, Dept. of Conservative Dentistry &
X-Ray was taken. On clinical examination,
Endodontics, Awadh Dental College & Hospital, a bony hard swelling on left side of the body
Jamshedpur. of the mandible with healed extracted
2
Prof & HOD, Dept. of Conservative Dentistry &
socket of tooth # 36. On vitality test tooth #
Endodontics, Dr. BR Ambedkar Institute of Dental
Sciences 35 and 37 were non vital. Radiographic
examination revealed a large oval

Vol.1 No. 3, July- Oct 2012 151


radiolucency well demarcated outline,
extending from periapical area of tooth # 35
to tooth # 37.In view of the clinical
symptoms and history, the provisional
diagnosis was Residual Cyst. The treatment
plan was first to surgically enucleation of the
cystic lesion and endodontic treatment of
tooth # 35 and # 37, so that, both the teeth can
be saved. On the day of surgery, the inferior
dental nerve block and long buccal nerve
anaesthesia was given with 2% lignocaine
with adreanaline. Mucoperiosteal flap was
reflected and with the help of surgical round
bur a bony window was made. The cystic
lesion while curetting out, the tooth # 37 was
mobile and without any bone support. So, it
was decided to take out and after full
debridement the whole bony cavity was
filled with alloplastic bone graft (BioGraft -
HT). Wound closure was obtained with a 3-0
black silk suture. Antibiotics (Co-amoxiclav
625mg), analgesic (Ibuprofen and
pracetamol combination) was prescribed
twice a day for five days and also 0.2%
Chlorhexidine mouth wash ( Clohex) was
also recommended for twice a day. The
enucleated specimen was sent for
histopathological examination.
Microscopical examination revealed a
residual cyst, stratified squamous epithelium
lining. Finally, root canal treatment was done
on tooth # 35. Root canal shaping was
Vol.1 No. 3, July- Oct 2012
Journal of Research and Advancement in Dentistry
done using K-flex hand files (Dentsply) and
obturation was done with Resilon and
Epiphany Obturation System(SybronEndo,
USA). The access cavity was sealed with a
temporary restorative material.
Radiographic imagesare routinely used in
the field of endodontics for diagnosis,
treatment planning, and follow-up of
periapical bone lesions. Radiographic
evaluation at one year recall revealed good
healing of the surgical cavity. Now the
patient is ready for permanent restoration
either bridge or implant.
Discussion:
Residual cyst is a type of inflammatory
odontogenic cyst development in the
edentulous alveolar ridge. It may occur due
to extraction of the tooth, leaving the
periapical pathology untreated or incomplete
removal of periapical granuloma or
periapical cyst. Theoretically, it could
develop in a dental granuloma that is left
afteran extraction2. A thorough history and
clinical examination is a must, to rule out
other primary odontogenic and
nonodontogenic cysts, tumors, and
metastatic lesions. In this case the patient
gave the history of extraction of grossly
decayed left lower first molar tooth three
years back from the local dentist without
taking an intra oral periapical x-ray. So, the
case was not properly diagnosed, and as a
result the decayed tooth extracted
152
 Journal of Research and Advancement in Dentistry

Fig. 1 pre operative OPG showing Fig 4 surgical procedure in

the the radiolucency in the mandible progress

Fig. 2 pre operative lateral oblique view

showing the the radiolucency in the Fig 5. post surgical procedure
mandible

Fig3. Swelling in the left side of body of Fig. 6 OPG after one year follow up,
mandible showing complete bone regeneration.

Vol.1 No. 3, July- Oct 2012 153


without doing any periapical curettage. This
might be the cause to develop residual cyst
with the involvement of the adjacent teeth,
second bicuspid and second molar. The bone
around second molar was severely destroyed
and that could not be saved, so, extraction of
that tooth was done. But the second bicuspid
though it was also involved by the lesion it
could be saved, as there was
enough bone support to retain the tooth. So,
RCT was carried out on lower left
secondbicuspid. The surgical defect was
filled with alloplastic bone graft for proper
bony contour and faster healing. BioGraft
HT is composed of biphasic synthetic
hydroxyapatite and beta tricalcium
phosphate with granule sizes 350-500
micron. Most periradicular lesions heal
uneventfully after conventional endodontic
treatment. However, some may require
surgical interventionto remove the
pathological tissue and simultaneously
eliminate the source of irritation that could
not be removed by the orthograde root canal
3
treatment . Bone regeneration after surgical
intervention takes place in a very slow
manner. Hence, to enhance these processes a
number of bone substitutes are being tried
out. The objective of using a bone graft is to
achieve successful and complete healing of
the bone. Bone grafts and bone regeneration
Vol.1 No. 3, July- Oct 2012
Journal of Research and Advancement in Dentistry
materials are being used with varying degree
of success. All these approaches are known
as regenerative therapies4,5. Bone grafting is
the most common form of regeneration
therapy. A variety of materials are available
for bone regeneration, which are highly
osteoconductive or osteoinductive like,
freeze dried bone graft, bioactive glass,
emdogain, PTR polymer, MTA, tricalcium
phosphate, and octacalcium phosphate6,7,8. In
1997, Whitman et al 9. , introduced Plarelet-
Rich Plasma (PRP). PRP increased the
density of bone when placed along with the
bone grafts10. But this type require special
apparatus and training, which was not
possible here at this moment. Though PRP
performed better when mixed with
hydroxyapatite or bone graft, but due to lack
of facility the procedure was not followed.
So, here only alloplastic bone grafts were
mixed with patients' own blood and
thoroughly compacted into the bony defect
until it reached the periphery of the bone
margins to regenerate bone. Radiographic
follow-up of the patient at the end of one year
showed complete bone regeneration. The
Resilon/Epiphany system (Pentron R
Clinical Technologies, LLC Wallingford)
was selected for obturation of the canals here
as because already it was hypothesized that if
a dental material could be developed that
would bond to the root canal walls,
154

the material would not only provide good
seal but may also reinforce the
endodontically treated teeth, which bonds
with dentine within the root canal producing
a Monoblock effect1. The advantages of
epiphany system include high radiopacity,
tissue compatibility, minimal shrinkage and
resorbability of sealer when expressed
periapically 1 2 . So, in this case the
Resilon/Epiphany system was followed
during obturation, after crown-down chemo-
mechanical preparation.
Conclusions:
1. Any radiolucent lesion in the jaw bones
must be thoroughly investigated before
undergoing any treatment procedures.
2. Proper history must be taken to make
diagnosis
3. In a clinical situation the use of bone
substitutes will definitely enhance bone
regeneration.
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