Case Report

Radicular Cyst, a Case Report and its

Histopathological Analysis
Vinayak Kumar Mantu1, Ruchi Mitra2
1
2

Senior Lecturer, Department of Oral and Maxillofacial Pathology, Darshan Dental College and Hospital, Loyara, Udaipur, Rajasthan, India,
SeniorResident, Department of Dentistry, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India

ABSTRACT
The radicular (periapical) cyst is the second most common pulp-periapical lesion. It is most common of all odontogenic cysts. The
radicular cyst is classified as an inflammatory cyst because it is a known fact that inflammatory products initiate the growth of the
epithelial component. Radicular cysts arise from the epithelial residues in the periodontal ligaments as a result of inflammation
usually following pulp death. The present case report is of a 16-year-old male patient with the complaint of pain in the upper front
tooth region of jaw since 3-4days. The present case report discusses the histopathological changes in detail about the previous
literature available so far.
Keywords: Epithelial, Inflammation, Odontogenic cyst, Periapical cyst, Periodontal ligament, Radicular cyst
Corresponding Author: Dr.Vinayak Kumar Mantu, Department of Oral and Maxillofacial Pathology, Darshan Dental college and Hospital,
Loyara, Udaipur-313011, Rajasthan, India. Phone: +91-9983824550. E-mail:drvinayakkm@gmail.com

INTRODUCTION
A radicular cyst is one of the most common odontogenic
cystic lesions, inflammatory in origin, which arises from
epithelial residues in the periodontal ligament. They
develop as a progression of untreated dental caries with
pulp necrosis and periapical infection.1 Around 60% of
all jaw, cysts are radicular or residual cysts. Many of the
studies have shown poor correlation between the size
of radiolucencies and histological findings of radicular
cysts.2 These cysts can occur in the periapical area of
any teeth, at any age but are rarely associated with
primary dentition.3 It is more frequent in maxillary than
mandibular teeth. They are the most common found at
the apices of the involved teeth, however, they may occur
on the lateral aspects of the roots in relation to lateral
accessory root canals. Radicular cysts are direct sequel to
chronic apical periodontitis but not every chronic lesion
develops into a cyst.4
The radicular cyst is usually symptomless and detected
incidentally on plain orthopantomogram (OPG) while
investigating for other diseases. However, as some of
them grow, they can cause mobility and displacement
of teeth and once infected, lead to pain and swelling,
after which the patient usually becomes aware of the
problem. The swelling is slowly enlarging and initially
9

bony hard to palpate which later becomes rubbery

and fluctuant.5,6 Radiographically, most radicular cysts
appear as round or pear shaped unilocular radiolucent
lesion in the periapical region. The cyst may displace
adjacent teeth or cause mild root resorption and can
even cause nerve compression. The treatment options for
radicular cyst can be conventional nonsurgical root canal
therapy when lesion is localized or surgical treatment
such as enucleation, marsupialization, or decompression
when the lesion is large.7 This case report presents the
histopathological analysis and the treatment plan of an
infected radicular cyst.

CASE REPORT
The 16-year-old male patient from Udaipur Rajasthan
was presented to the Department of Oral Pathology,
Darshan Dental College Udaipur with complains of
pain in the upper front tooth region of jaw since 3-4days
(Figure1). The pain was sudden, severe, sharp and
continuous, occurs on chewing food, radiates to the
forehead at night. Pain aggravated on eating and relieved
after taking a tablet and subsided for 6-8 h. There was
no relevant Medical, dental, and family history. Personal
history included brushing habit once daily and had a
mixed diet. Intraoral examination revealed that pain was
present on palpation of palatal mucosa in relation to 21,

International Journal of Advanced Health Sciences Vol 2 Issue 5 September 2015

Mantu, and Mitra

Radicular Cyst; a Case Report

22. There was no extra oral swelling and intraorally the

palatal mucosa was firm and palpable in 21, 22 root apex
(Figure2). On inspection of the swelling, it was one in
number, present in the maxillary front region, pink color,
margins irregular, smooth surface, and pulsation absent.
On palpation temperature was afebrile, shape ovoid, size
1cm 1cm, tender, soft in consistency and fluctuation
absent. Vitality test conducted revealed no response
in 21, 22 teeth. Affected teeth were slightly tender on
percussion and showed GradeI mobility. The cyst was
curetted by raising the flap and tissue was submitted
for histopathological examination. The provisional
diagnosis was suggested as palatal abscess with 21. With
the differential diagnosis of the radicular cyst, periapical
granuloma, globulomaxillary cyst, the hematological
investigations were done. Hemoglobin-11.8 g/dl and
total leukocyte count-7700/cumm were observed.
Intraoral Periapical and Intraoral Maxillary Occlusal
Radiograph
It shows well-defined cortical border with the
radiolucency at the apical region wrt 21, 22 measuring

about 1cm 1cm. Bone resorption adjacent to the lesion

was seen (Figure3a and b).
Histological Analysis
The presence of varying thickness of epithelium fibro
cellular connective stroma. In scanner view, one-bit of
tissue with epithelium and underlying connective tissue
stroma (Figure4).
Low power view, showed stratified squamous
hyperplastic epithelium with arcading pattern of rete
ridges and underlying dense fibro cellular connective
tissue stroma consisting of sparsely arranged collagen
fibers, fibroblasts and few vascular spaces with
extravasated red blood cells (Figure5).
High power view showed diffuse and dense infiltration
of chronic inflammatory cells along with vacuolations.
Connective tissue showed dense infiltration of lymphocytes
and plasma cells with few macrophages (Figure6).
The clinical, radiographic, hematological and histological
examination concluded Radicular cyst with 21 as the
final diagnosis. Therefore, the treatment plan included
oral-antibiotics and analgesics, personal oral hygiene
and diet counseling, oral prophylaxis, RCT wrt 21,
22. The Surgical treatment included enucleation of
cyst/marsupialization and plasma rich protein graft.

DISCUSSION
The radicular (periapical) cyst is the second most
common pulpoperiapical lesion. It is classified as an

Figure 1: Facial view of the patient

Figure 3: (a) Intraoral periapical. (b) Maxillary occlusal view

Figure 2: Intraoral view with cyst wrt 21, 22

Figure 4: Scanner view

International Journal of Advanced Health Sciences Vol 2 Issue 5 September 201510

Radicular Cyst; a Case Report

Mantu, and Mitra

multinucleated giant cells and neutrophils were also

observed in the cysts. These features are comparable
to those described previously.12 The histopathological
studies show that the epithelial lining of almost all
radicular cysts is whole or in part lined by stratified
Squamous Epithelium and range in thickness from
1to 50 cell layers.11 Keratinization was not found in the
present case.
In approximately 10% of cases of radicular cysts,
Rushtons Hyaline bodies are found in epithelial linings.
Rushton bodies or hyaline bodies exhibiting a wide
variety of shapes, including linear, round, lamellar or
amorphous structures, were found in the epithelium of
RCs.13 The presence of these structures depends on the
sectioning plane of the material, with their incidence
ranging from 2.6% to 10.3%. In the present study,
Rushton bodies were detected in only a few cells. They
presented a lamellar shape without calcifications.

Figure 5: Under low power

Figure 6: Under high power

odontogenic cyst because of its origin in the cell rest of

mallasez in the periodontal ligament cells, which are
remnants of the Hertwig root sheath; the latter, in turn, is
a product of the odontogenic epithelial layers (the inner
and outer enamel epithelium). Quite often a radicular
cyst remains behind in the jaws after removal of the
offending tooth, and this is referred to as a residual cyst.8
The pathogenesis of radicular cysts has been described
as comprising of three distinct phases: The phase of
initiation, the phase of cyst formation, and the phase of
enlargement.9
The initial swellings of these radicular cysts are usually
bony hard, but as they increase in size, the covering bone
may become very thin despite initial sub-periosteal bone
deposition. Finally, with progressive bone resorption, the
swellings exhibit springiness or egg shell crackling.
The associated teeth are always non-vital, and may show
discoloration. Although the associated teeth usually
show no root resorption, there may be smooth resorption
of root apices.10,11
Histologically, the lesions fulfilled the criteria adopted
for radicular cysts. They consisted of a cystic wall lined
by stratified non-keratinized squamous epithelium,
sometimes arranged in often interconnecting rings,
which exhibited spongiosis and exocytosis and was
hyperplastic or atrophic. Chronic inflammatory infiltrate,
11

Another observant feature is the deposition of cholesterol

crystals found in many radicular cysts through
degeneration and disintegration of lymphocytes, plasma
cells and macrophages taking part in the inflammatory
process.11 With the acute inflammatory cells present
when epithelium is proliferating, chronic inflammatory
cells are present in the connective tissue immediately
adjacent to the epithelium.
These cysts can occur in the periapical region of any
teeth, at any age but seldom seen associated with the
primary dentition.14 Few studies in the UK and the
South African population have shown that radicular
cysts occur more commonly between the third and fifth
decades of life, more common in males than females, and
more frequently found in the anterior maxilla than other
parts of the mouth.15 Its size rarely exceeds 1cm and is
often seen in patients between 30 and 50years old with
the higher incidence in the maxillary anterior region.13
Inthe present case, the patient was in the second decade,
and the size was 1cm 1cm present in the anterior
maxillary region.
The treatments of these cysts are still under discussion,
and many professionals opt for a conservative treatment
using the endodontic technique.16 However, in large
lesions the endodontic treatment alone is not efficient,
and it should be associated to a decompression or a
marsupialization or even to enucleation.17 In the present
case, endodontic treatment along with enucleation was
suggested.
The radicular cyst is usually symptomless and detected
incidentally on plain OPG while investigating for other
diseases. However, as some of them grow, they can cause
mobility and displacement of teeth and once infected,

International Journal of Advanced Health Sciences Vol 2 Issue 5 September 2015

Mantu, and Mitra

Radicular Cyst; a Case Report

lead to pain and swelling, after which the patient usually

becomes aware of the problem. The swelling is slowly
enlarging and initially bony hard to palpate which later
becomes rubbery and fluctuant18 similar to our clinical
findings.

7.
8.
9.

CONCLUSION

10.

A radicular cyst is a common condition, and it usually goes

unnoticed and rarely exceeds the palpable dimension.
Untreated cases may lead to tissue destructions and
facial deformity. Hence this case, however, occurs in an
uncommon age group, but clinical and histopathological
findings were similar to previous literature and were
successfully treated endodontically followed by surgical
enucleation.

11.
12.
13.
14.
15.

REFERENCES
1.

Aslan A, Simsek G. Large residual dental cyst A case report. J

Dent Facult Ataturk Univ 2002;12:45-9.
2. Jones AV, Craig GT, Franklin CD. Range and demographics of
odontogenic cysts diagnosed in a UK population over a 30-year
period. JOral Pathol Med 2006;35:500-7.
3. Joshi UK, Patil SK, Siddiqua A. Nasopalatine cyst a rare entity.
Int J Dent Clin 2010;2:34-6.
4. Kannan N, Patil R, Sreenivasalu P. Bilateral maxillary dentigerous
cysts a case report. Int J Dent Clin 2010;2:25-9.
5. Lin LM, Huang GT, Rosenberg PA. Proliferation of epithelial cell
rests, formation of apical cysts, and regression of apical cysts
after periapical wound healing. J Endod 2007;33:908-16.
6. Gallego Romero D, Torres Lagares D, GarcIa Caldern M, Romero
Ruiz MM, Infante Cossio P, Gutirrez Prez JL. Differential
diagnosis and therapeutic approach to periapical cysts in daily

16.
17.

18.

dental practice. Med Oral 2002;7:54-62.

Shear M. Radicular and residual cysts. In: Cysts of the Oral Region.
3rded. Bristol: Wright; 1992. p.136-62.
Cawson RA, Odell EW, Porter S. Cawson`s Essentials of Oral
Pathology and Oral Medicine. 7 thed. Edinburgh: Churchill
Livingstone; 2002. p.102-21.
Jansson L, Ehnevid H, Lindskog S, Blomlf L. Development of
periapical lesions. Swed Dent J 1993;17:85-93.
Lustmann J, Shear M. Radicular cysts arising from deciduous
teeth. Review of the literature and report of 23cases. Int J Oral
Surg 1985;14:153-61.
Brave D, Madhusudan AS, Ramesh G, Brave VR. Radicular cyst
of anterior maxilla. Int J Dent Clin 2011;3:16-7.
Moreira PR, Santos DF, Martins RD, Gomez RS. CD57cells in
radicular cyst. Int Endod J 2000;33:99-102.
Cohen M. A review of Rushton hyaline bodies. Diastema
1976;4:30-3, 35-6.
Grewal HK, Batra R. Non syndromic bilateral dentigerous cysts A
case report. Int J Dent Clin 2010;2:49-51.
Joshi NS, Sujan SG, Rachappa MM. An unusual case report
of bilateral mandibular radicular cysts. Contemp Clin Dent
2011;2:5962.
Hoen MM, LaBounty GL, Strittmatter EJ. Conservative treatment
of persistent periradicular lesions using aspiration and irrigation.
JEndod 1990;16:182-6.
Danin J, Linder LE, Lundqvist G, Ohlsson L, Ramskld LO,
Strmberg T. Outcomes of periradicular surgery in cases with
apical pathosis and untreated canals. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 1999;87:227-32.
Natkin E, Oswald RJ, Carnes LI. The relationship of lesion size
to diagnosis, incidence, and treatment of periapical cysts and
granulomas. Oral Surg Oral Med Oral Pathol 1984;57:82-94.

How to cite this article: Mantu VK, Mitra R. Radicular Cyst, A Case Report
and Its Histopathological Analysis. Int J Adv Health Sci 2015;2(5):9-12.
Source of Support: Nil, Conflict of Interest: None declared.

International Journal of Advanced Health Sciences Vol 2 Issue 5 September 201512