CORRESPONDENCE
Treatment of a Large Radicular Cyst To the Editor: Bacterial contamination of the pulp tissue may develop the periapical lesions, such as periapical granuloma, periapical abscess, or radicular cyst (RC).1 They are usually diagnosed by routine radiographic examination, which may be accompanied or not by acute pain in the tooth involved.2 –4 In this context, the RC may have its preliminary clinical diagnosis based on the following clinical and radiographic findings: involvement of lesion with 1 or more nonvital teeth; to be greater than 200 mm2 in size; to present radiographically as a circumscribed, well-defined radiolucent area bound by a thin radiopaque line; and produces a straw-colored fluid upon aspiration.2,3 However, the definitive diagnosis of an RC may be made only by a histological examination.3 The aim of this study was to describe the treatment of a large RC decompression technique associated with endodontic treatment.
CLINICAL REPORT A 33-year-old woman presented to the stomatology clinic complaining about increased volume in the face. The extraoral examination revealed tumefaction in maxilla of the right side. In intraoral examination, swelling of the right upper maxillary region was observed in which the tooth in question exhibited negative response to pulp sensitivity test. The radiographic examination showed a circumscribed, well-defined radiolucent area bound by a thin radiopaque line, which expanded to the area of the right maxillary sinus (Figs. 1A, B). In agreement, the coronal computed tomographic scan confirmed a 4 2 3.5-cm lesion (Fig. 1C). This way, the differential diagnosis included RC, ossifying fibroma, odontogenic tumor, giant cell tumor, and odontogenic cyst. Needle aspiration was performed revealing a straw-colored fluid (Fig. 1D). After the confirmation of cystic lesion, decompression was performed (Fig. 1E), and the patient was administered antibiotics and anti-inflammatory drugs. The Valsalva maneuver
did not show buccosinusal communications. Tissues collected were sent for histopathologic analysis, which showed compatibility with RC. Thus, the endodontic treatment was initiated during the cystic decompression period, conducting periodic exchanges of calcium hydroxide and hermetic obturation of root canals (Fig. 1F). After 15 days of cystic decompression, the drain was removed. The patient was advised the keep the cystic cavity clean through applying saline solution with aid of syringe and needle. The cystic decompression period lasted 10 months, which was finished with surgery to remove the fistula. After 6 months, the lesion reduced considerably (Fig. 1G), and after 1 year occurred complete regression was observed (Fig. 1H).
DISCUSSION Radicular cyst is the most common injury among periapical lesions.1,3,4 According to Kontogiannis et al,1 the RC represents 64.91% of periapical lesion. The differential diagnosis of RC may include dentigerous cyst, eruption cyst, residual cyst, paradental cyst, glandular odontogenic cyst, lateral periodontal cyst, gingival cyst, incisive canal cyst, traumatic bone cyst, and odontogenic tumors.3 Our differential diagnosis in this clinical report was determined because of the size and location of lesion, dental pulp devitalization, and radiographic images. It is necessary to emphasize that the dental pulp devitalization favors the development of periapical lesion, as well as fibro-osseous lesions.1 Thus, the early diagnosis associated to endodontic treatment may prevent the appearance and development of the lesion. In case of intraosseous lesions, needle aspiration is important to differentiate cystic lesions from solid lesions such as neoplasms. In our case, as cystic lesion was shown positive, decompression technique was performed. In the literature, different therapies are proposed, such as conservative root canal treatment without adjunctive therapy, decompression technique, active nonsurgical decompression technique, aspiration through the root canal technique, marsupialization, apical resection, and surgical enucleation,2,4,5 besides the association among techniques.6 In our case, decompression technique associated with endodontic treatment was performed by the fact that the endodontic treatment removes bacterial contamination in root canals, by instrumentation and irrigation of the root canal and use of medication intraradicularly,7 acting in the stimulation of apoptosis in cystic cells.8 In conclusion, decompression technique associated with endodontic treatment was effective for the treatment of a large RC. Therefore, a conservative therapy should be performed prior to performing more invasive therapies. Victor Eduardo de Souza Batista, DDS, MSc Department of Dental Materials and Prosthodontics Arac¸atuba Dental School UNESP–Univ Estadual Paulista Campus of Arac¸atuba Sa˜o Paulo, Brazil [email protected] Fa´bio Roberto de Souza Batista, DDS Department of Oral and Maxillofacial Surgery School of Dentistry State University of Maringa´ –UEM Parana´, Brazil
FIGURE 1. A, Panoramic radiography. B, Enlarged view of the lesion area. C, Coronal computed tomographic scan. D, Needle aspiration revealing a strawcolored fluid. E, Decompression technique. F, Periapical radiographic examinations after hermetic obturation of root canals. G, Follow-up 6 months after obturation of root canals. H, Follow-up 12 months after obturation of root canals.
e454
Marceli Moc¸o Silva, DDS, MSc Department of Dentistry Adamantina Dental School FAI–Faculdades Adamantinenses Integradas, Adamantina Sa˜o Paulo, Brazil
The Journal of Craniofacial Surgery
Volume 26, Number 5, July 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 5, July 2015
Correspondence
REFERENCES 1. Kontogiannis TG, Tosios KI, Kerezoudis NP, et al. Periapical lesions are not always a sequelae of pulpal necrosis: a retrospective study of 1521 biopsies. Int Endod J 2015;48:68–73 2. Fernandes M, de Ataide I. Nonsurgical management of periapical lesions. J Conserv Dent 2010;13:240–245 3. Sagit M, Guler S, Tasdemir A, et al. Large radicular cyst in the maxillary sinus. J Craniofac Surg 2011;22:e64–e65 4. Kocyigit ID, Atil F, Alp YE, et al. Piezosurgery versus conventional surgery in radicular cyst enucleation. J Craniofac Surg 2012;23:1805– 1808 5. Sa´nchez-Torres A, Sa´nchez-Garce´s MA, Gay-Escoda C. Materials and prognostic factors of bone regeneration in periapical surgery: a systematic review. Med Oral Patol Oral Cir Bucal 2014;19: e419–e425 6. Thomas K, T PD, Simon EP.;1; Management of large periapical cystic lesion by aspiration and nonsurgical endodontic therapy using calcium hydroxide paste. J Contemp Dent Pract 2012;13:897–901 7. Leonardo MR, Silveira FF, Silva LA, et al. Calcium hydroxide root canal dressing. Histopathological evaluation of periapical repair at different time periods. Braz Dent J 2002;13:17–22 8. Lin LM, Ricucci D, Lin J, et al. Nonsurgical root canal therapy of large cyst-like inflammatory periapical lesions and inflammatory apical cysts. J Endod 2009;35:607–615
Ectopic Third Molar Tooth at the Mandibular Notch To the Editor: Impacted mandibular third molars are a common condition and usually locate between the second molar and ramus. Ectopic mandibular third molars are very rare; only few cases have been reported, and the etiology is little understood.1 These reports showed only the result of the ectopic location of the third molar. Here, we report a first case of ectopic third molar at the mandibular notch, in which the third molar tooth had moved retrogradely from between the second molar and ramus to mandibular notch in an upward direction over a long time. The patient was a 58-year-old woman complaining chiefly of discomfort in the left buccal mucosa. Eighteen years ago, the patient had a similar symptom, and a panoramic radiograph was taken by her dentist. The panoramic radiograph revealed that the left lower second molar had apical periodontitis, and the third molar tooth was impacted between the mandibular body and ramus (Fig. 1A). The left lower second molar was extracted, and the third molar tooth was not treated at this time. The current panoramic radiograph and computed tomography showed the impacted third molar tooth was in the left mandibular notch with radiolucency around the crown (Figs. 1B, C). The tooth was extracted via an incision on the anterior edge of the mandibular ramus under general anesthesia. The soft tissue around the crown was removed and diagnosed as granulation tissue pathologically. Migration in forward direction of ectopic second molar at the condyle has been reported, which was observed in sequential radiographs.2 However, there are no reports on the process of the retrograde migration of the ectopic third molar in the time course. There are some theories to explain the ectopic location of the mandibular third molars such as aberrant eruption, trauma, and ectopic formation of the germs of the tooth. A mandibular third #
2015 Mutaz B. Habal, MD
FIGURE 1. A, Initial panoramic radiographs showing the third molar tooth was impacted between the mandibular body and ramus (arrow). B, A current panoramic radiograph showing the impacted third molar tooth was in the left mandibular notch with radiolucency around the crown 18 years after the first radiograph (arrow). C, A current computed tomography.
molar tooth may be displaced by odontogenic tumor or dentigerous cysts.3 In our case, there was granulation tissue with chronic inflammation around the crown, which may have the potential to force up the tooth to the unusual anatomical site. Makoto Adachi, DDS, PhD Masayuki Motohashi, DDS, PhD Masahiro Nakashima, DDS, PhD Yuichi Ehara, DDS, PhD Munehiro Azuma, DDS Yasunori Muramatsu, DDS, PhD Department of Oral and Maxillofacial Surgery Asahi University Murakami Memorial Hospital Gifu, Japan [email protected]
REFERENCES 1. Iglesias-Martin F, Infante-Cossio P, Torres-Carranza E, et al. Ectopic third molar in the mandibular condyle: a review of the literature. Med Oral Patol Oral Cir Bucal 2012;17:e1013–e1017
e455
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Treatment of a Large Radicular Cyst To the Editor: Bacterial contamination of the pulp tissue may develop the periapical lesions, such as periapical granuloma, periapical abscess, or radicular cyst (RC).1 They are usually diagnosed by routine radiographic examination, which may be accompanied or not by acute pain in the tooth involved.2 –4 In this context, the RC may have its preliminary clinical diagnosis based on the following clinical and radiographic findings: involvement of lesion with 1 or more nonvital teeth; to be greater than 200 mm2 in size; to present radiographically as a circumscribed, well-defined radiolucent area bound by a thin radiopaque line; and produces a straw-colored fluid upon aspiration.2,3 However, the definitive diagnosis of an RC may be made only by a histological examination.3 The aim of this study was to describe the treatment of a large RC decompression technique associated with endodontic treatment.
CLINICAL REPORT A 33-year-old woman presented to the stomatology clinic complaining about increased volume in the face. The extraoral examination revealed tumefaction in maxilla of the right side. In intraoral examination, swelling of the right upper maxillary region was observed in which the tooth in question exhibited negative response to pulp sensitivity test. The radiographic examination showed a circumscribed, well-defined radiolucent area bound by a thin radiopaque line, which expanded to the area of the right maxillary sinus (Figs. 1A, B). In agreement, the coronal computed tomographic scan confirmed a 4 2 3.5-cm lesion (Fig. 1C). This way, the differential diagnosis included RC, ossifying fibroma, odontogenic tumor, giant cell tumor, and odontogenic cyst. Needle aspiration was performed revealing a straw-colored fluid (Fig. 1D). After the confirmation of cystic lesion, decompression was performed (Fig. 1E), and the patient was administered antibiotics and anti-inflammatory drugs. The Valsalva maneuver
did not show buccosinusal communications. Tissues collected were sent for histopathologic analysis, which showed compatibility with RC. Thus, the endodontic treatment was initiated during the cystic decompression period, conducting periodic exchanges of calcium hydroxide and hermetic obturation of root canals (Fig. 1F). After 15 days of cystic decompression, the drain was removed. The patient was advised the keep the cystic cavity clean through applying saline solution with aid of syringe and needle. The cystic decompression period lasted 10 months, which was finished with surgery to remove the fistula. After 6 months, the lesion reduced considerably (Fig. 1G), and after 1 year occurred complete regression was observed (Fig. 1H).
DISCUSSION Radicular cyst is the most common injury among periapical lesions.1,3,4 According to Kontogiannis et al,1 the RC represents 64.91% of periapical lesion. The differential diagnosis of RC may include dentigerous cyst, eruption cyst, residual cyst, paradental cyst, glandular odontogenic cyst, lateral periodontal cyst, gingival cyst, incisive canal cyst, traumatic bone cyst, and odontogenic tumors.3 Our differential diagnosis in this clinical report was determined because of the size and location of lesion, dental pulp devitalization, and radiographic images. It is necessary to emphasize that the dental pulp devitalization favors the development of periapical lesion, as well as fibro-osseous lesions.1 Thus, the early diagnosis associated to endodontic treatment may prevent the appearance and development of the lesion. In case of intraosseous lesions, needle aspiration is important to differentiate cystic lesions from solid lesions such as neoplasms. In our case, as cystic lesion was shown positive, decompression technique was performed. In the literature, different therapies are proposed, such as conservative root canal treatment without adjunctive therapy, decompression technique, active nonsurgical decompression technique, aspiration through the root canal technique, marsupialization, apical resection, and surgical enucleation,2,4,5 besides the association among techniques.6 In our case, decompression technique associated with endodontic treatment was performed by the fact that the endodontic treatment removes bacterial contamination in root canals, by instrumentation and irrigation of the root canal and use of medication intraradicularly,7 acting in the stimulation of apoptosis in cystic cells.8 In conclusion, decompression technique associated with endodontic treatment was effective for the treatment of a large RC. Therefore, a conservative therapy should be performed prior to performing more invasive therapies. Victor Eduardo de Souza Batista, DDS, MSc Department of Dental Materials and Prosthodontics Arac¸atuba Dental School UNESP–Univ Estadual Paulista Campus of Arac¸atuba Sa˜o Paulo, Brazil [email protected] Fa´bio Roberto de Souza Batista, DDS Department of Oral and Maxillofacial Surgery School of Dentistry State University of Maringa´ –UEM Parana´, Brazil
FIGURE 1. A, Panoramic radiography. B, Enlarged view of the lesion area. C, Coronal computed tomographic scan. D, Needle aspiration revealing a strawcolored fluid. E, Decompression technique. F, Periapical radiographic examinations after hermetic obturation of root canals. G, Follow-up 6 months after obturation of root canals. H, Follow-up 12 months after obturation of root canals.
e454
Marceli Moc¸o Silva, DDS, MSc Department of Dentistry Adamantina Dental School FAI–Faculdades Adamantinenses Integradas, Adamantina Sa˜o Paulo, Brazil
The Journal of Craniofacial Surgery
Volume 26, Number 5, July 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 5, July 2015
Correspondence
REFERENCES 1. Kontogiannis TG, Tosios KI, Kerezoudis NP, et al. Periapical lesions are not always a sequelae of pulpal necrosis: a retrospective study of 1521 biopsies. Int Endod J 2015;48:68–73 2. Fernandes M, de Ataide I. Nonsurgical management of periapical lesions. J Conserv Dent 2010;13:240–245 3. Sagit M, Guler S, Tasdemir A, et al. Large radicular cyst in the maxillary sinus. J Craniofac Surg 2011;22:e64–e65 4. Kocyigit ID, Atil F, Alp YE, et al. Piezosurgery versus conventional surgery in radicular cyst enucleation. J Craniofac Surg 2012;23:1805– 1808 5. Sa´nchez-Torres A, Sa´nchez-Garce´s MA, Gay-Escoda C. Materials and prognostic factors of bone regeneration in periapical surgery: a systematic review. Med Oral Patol Oral Cir Bucal 2014;19: e419–e425 6. Thomas K, T PD, Simon EP.;1; Management of large periapical cystic lesion by aspiration and nonsurgical endodontic therapy using calcium hydroxide paste. J Contemp Dent Pract 2012;13:897–901 7. Leonardo MR, Silveira FF, Silva LA, et al. Calcium hydroxide root canal dressing. Histopathological evaluation of periapical repair at different time periods. Braz Dent J 2002;13:17–22 8. Lin LM, Ricucci D, Lin J, et al. Nonsurgical root canal therapy of large cyst-like inflammatory periapical lesions and inflammatory apical cysts. J Endod 2009;35:607–615
Ectopic Third Molar Tooth at the Mandibular Notch To the Editor: Impacted mandibular third molars are a common condition and usually locate between the second molar and ramus. Ectopic mandibular third molars are very rare; only few cases have been reported, and the etiology is little understood.1 These reports showed only the result of the ectopic location of the third molar. Here, we report a first case of ectopic third molar at the mandibular notch, in which the third molar tooth had moved retrogradely from between the second molar and ramus to mandibular notch in an upward direction over a long time. The patient was a 58-year-old woman complaining chiefly of discomfort in the left buccal mucosa. Eighteen years ago, the patient had a similar symptom, and a panoramic radiograph was taken by her dentist. The panoramic radiograph revealed that the left lower second molar had apical periodontitis, and the third molar tooth was impacted between the mandibular body and ramus (Fig. 1A). The left lower second molar was extracted, and the third molar tooth was not treated at this time. The current panoramic radiograph and computed tomography showed the impacted third molar tooth was in the left mandibular notch with radiolucency around the crown (Figs. 1B, C). The tooth was extracted via an incision on the anterior edge of the mandibular ramus under general anesthesia. The soft tissue around the crown was removed and diagnosed as granulation tissue pathologically. Migration in forward direction of ectopic second molar at the condyle has been reported, which was observed in sequential radiographs.2 However, there are no reports on the process of the retrograde migration of the ectopic third molar in the time course. There are some theories to explain the ectopic location of the mandibular third molars such as aberrant eruption, trauma, and ectopic formation of the germs of the tooth. A mandibular third #
2015 Mutaz B. Habal, MD
FIGURE 1. A, Initial panoramic radiographs showing the third molar tooth was impacted between the mandibular body and ramus (arrow). B, A current panoramic radiograph showing the impacted third molar tooth was in the left mandibular notch with radiolucency around the crown 18 years after the first radiograph (arrow). C, A current computed tomography.
molar tooth may be displaced by odontogenic tumor or dentigerous cysts.3 In our case, there was granulation tissue with chronic inflammation around the crown, which may have the potential to force up the tooth to the unusual anatomical site. Makoto Adachi, DDS, PhD Masayuki Motohashi, DDS, PhD Masahiro Nakashima, DDS, PhD Yuichi Ehara, DDS, PhD Munehiro Azuma, DDS Yasunori Muramatsu, DDS, PhD Department of Oral and Maxillofacial Surgery Asahi University Murakami Memorial Hospital Gifu, Japan [email protected]
REFERENCES 1. Iglesias-Martin F, Infante-Cossio P, Torres-Carranza E, et al. Ectopic third molar in the mandibular condyle: a review of the literature. Med Oral Patol Oral Cir Bucal 2012;17:e1013–e1017
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
