Slowly enlarging swelling of the anterior maxilla

§Chief complaint

Painless swelling of the upper front gum for 8 months

§Medical & dental history

• 01Unremarkable, no systemic disease
• 02Non-smoker, no drug allergy
• 03Trauma to upper anterior teeth in a road accident 12 years ago
• 04Never sought treatment; tooth gradually discoloured

§Clinical examination

• 01Ovoid buccal swelling 21 x 18 mm over 11/21, mucosa normal colour
• 02Egg-shell crackling on firm palpation; non-tender
• 0311 discoloured greyish, non-responsive to cold and electric pulp testing
• 04No lymphadenopathy, no paraesthesia

§ figuresFigures (4)

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§Differential diagnosis

§Final diagnosis

Radicular (periapical) cyst associated with non-vital 11

The pivotal findings are a non-vital, previously traumatised tooth and a well-corticated, round periapical radiolucency continuous with the lamina dura. Vitality testing separates radicular cyst from nasopalatine duct cyst and OKC; size and corticated margin separate it from a granuloma.

§Investigations

• 01Periapical and OPG radiographs — unilocular corticated radiolucency 20 mm at apex of 11
• 02CBCT — buccal cortical expansion with intact thin cortex, no root resorption of 21
• 03Pulp sensibility testing of 11, 12, 21, 22
• 04Aspiration — straw-coloured cholesterol-containing fluid

§Treatment plan

• 01Root canal treatment of 11
• 02Enucleation of cyst lining with primary closure
• 03Histopathological examination of the entire specimen

§Surgical procedure

• 01Local anaesthesia, trapezoidal mucoperiosteal flap 12-22
• 02Buccal window osteotomy, cyst enucleated in one piece
• 03Apicectomy of 11 with 3 mm root-end resection and MTA retrograde seal
• 04Bony cavity irrigated, flap repositioned with 4-0 resorbable sutures

§Histopathology report

Cystic cavity lined by non-keratinised stratified squamous epithelium of variable thickness with arcading rete ridges; fibrous wall with dense chronic inflammatory infiltrate, cholesterol clefts and Rushton bodies. No dysplasia. Consistent with radicular cyst.

§Follow-up & outcome

• 011 week — suture removal, uneventful healing
• 026 months — progressive bony infill on periapical radiograph
• 0324 months — complete radiographic resolution, tooth asymptomatic

§Clinical pearls / learning points

• 01Every periapical radiolucency must be correlated with pulp vitality before it is called a cyst.
• 02Send every enucleated lining for histopathology — occasional OKC and even carcinoma are found in 'obvious' radicular cysts.
• 03Egg-shell crackling indicates an expanded but still intact cortex.

§References

• Neville BW et al. Oral and Maxillofacial Pathology, 5th ed.
• WHO Classification of Head and Neck Tumours, 5th ed. (2022).

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