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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 3  |  Page : 137-140

Management of a nonvital discolored tooth associated with radicular cyst: A multidisciplinary approach


1 Department of Conservative Dentistry and Endodontics, Army Dental Centre, Research and Referral Army Hospital, New Delhi, India
2 Department of Conservative Dentistry and Endodontics, Saraswati Dental College and Hospital, New Delhi, India
3 Consultant Endodontist, New Delhi, India

Date of Submission17-May-2020
Date of Acceptance04-Aug-2020
Date of Web Publication21-Dec-2020

Correspondence Address:
Dr. Richa Gupta
H-150, Ashok Vihar, Phase 1, Delhi - 110 052
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_35_20

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   Abstract 


The radicular cyst arises from proliferated epithelial cell rests of malassez when they get stimulated by an inflammatory process originating from pulpal necrosis of a nonvital tooth. The associated tooth is usually asymptomatic and may result in swelling of the soft tissues and mobility of the teeth involved. The typical radiographic description of the lesion is a round or oval, well-circumscribed radiolucency involving the apex of the tooth. Radicular cysts can be managed either surgically or nonsurgically. The nonvital, discolored anterior tooth associated with the lesion is a common esthetic concern for patients. It can effect their self-confidence and employability. Discolored nonvital teeth are frequently compromised due to root canal treatment, previous trauma, or caries. Invasive treatment options like crowns or veneers further weaken the tooth structure. This case report presents the successful surgical management of a radicular cyst associated with a nonvital discolored anterior tooth. This will also include the technicalities involved in the inside/outside nonvital bleaching technique.

Keywords: Biodentine, bleaching, cone.beam computed tomography, enucleation, nonvital, tooth discoloration


How to cite this article:
Gupta R, Bhagabati N, Jain G, Ahlawat J. Management of a nonvital discolored tooth associated with radicular cyst: A multidisciplinary approach. J Interdiscip Dentistry 2020;10:137-40

How to cite this URL:
Gupta R, Bhagabati N, Jain G, Ahlawat J. Management of a nonvital discolored tooth associated with radicular cyst: A multidisciplinary approach. J Interdiscip Dentistry [serial online] 2020 [cited 2021 Jan 22];10:137-40. Available from: https://www.jidonline.com/text.asp?2020/10/3/137/304153




   Clinical Relevance to Interdisciplinary Dentistry Top


This case of Non-vital discolored tooth which was associated with a radicular cyst involved an interdisciplinary approach requiring endodontic treatment of the involved non vital teeth which was followed by a periapical surgery to enucleate the radicular cyst and later on after months of follow up, a conservative approach to treat the dicoloration using non-vital bleaching instead of giving a full coverage restoration which would have compromised the already weakened tooth structure.


   Introduction Top


The radicular cyst is the most common odontogenic cyst of inflammatory origin affecting the jaws. It is commonly found at the apex of the tooth involved; however, it may also be found on the lateral aspect of the root in relation to lateral accessory canals.[1] Many periapical cysts are symptomless and are discovered only when intraoral swelling appears over a period of time and a periapical radiograph is taken. Over the years, the cyst may remain static, regress, or grow in size. The treatment of the cysts can be either nonsurgical or surgical management being either marsupialization or enucleation. Discolored nonvital anterior tooth due to trauma or endodontic treatment can cause considerable esthetic compromise to patients. The management of tooth discoloration includes veneers, crowns, and noninvasive techniques such as bleaching.[2] Though this restorative crown or veneer approach is one of the most predictable methods, it involves the removal of tooth structure. Nonvital bleaching has many benefits since it is a noninvasive procedure and more economical. The three most popular techniques for nonvital tooth bleaching are the walking bleach technique, inside/outside bleaching, and in-office bleaching. It is easy to see the potential benefits of using the inside/outside bleaching technique for nonvital cases compared with other bleaching techniques. In this technique, greater surface area is bleached at a time as the agent is applied to the external and internal aspects of the discolored tooth.[3]


   Case Report Top


A 35-year-old male patient reported to the Department of Conservative Dentistry and Endodontics, Army dental center, Research and referral army hospital with a chief complaint of swelling in the palatal region for the last 1 month. The patient gave a history of trauma in upper anterior teeth 5 years back. On intraoral examination, Tooth 21 was discolored, the swelling was present in the palatal region, which was extending from 21 to 22 region [Figure 1]a and [Figure 1]b. The swelling was soft and fluctuant in nature. Thermal and electrical pulp sensitivity testing was negative with respect to 21, 22, while adjacent teeth showed a normal response. Teeth were painless to vertical percussion. Initially, an intra oral periapical radiograph (IOPA) was taken, which could not cover the whole radiolucency [Figure 1]c, and hence, a cone-beam computed tomography (CBCT) was advised to know the full extent of the lesion. Preoperative CBCT revealed the presence of a single large radiolytic lesion within anterior maxilla extending mediolaterally (ML) from midline up to mesial of 23 measuring about 15.9 mm ML × 11.7 mm anteroposteriorly (AP) × 12.1 mm cranio-caudally involving the periapical region of 21, 22 [Figure 1]d. A fine-needle aspiration of the swelling revealed straw-colored fluid. From the history and clinical examination, a provisional diagnosis of the radicular cyst with respect to 21, 22 was made and differential diagnosis of benign salivary gland neoplasm or neoplasm of the maxillary sinus and was considered. The treatment plan was formulated, which included root canal treatment with respect to 21, 22 followed by surgical enucleation of cyst and apicectomy of 21, 22. The treatment procedure was explained to the patient, and informed consent was obtained. Root canal treatment with respect to 21, 22 was started and working length determined After complete chemomechanical preparation, calcium hydroxide (I-Dent, India) was used as an intracanal medicament for 1 week. In the next visit, root canal treatment was completed, followed by surgical enucleation of cyst, apicectomy and retrograde filling of involved teeth with biodentine (Septodont, USA). The procedure is as follows: after administration of local anesthesia (2% lignocaine), crevicular incision was given in the labial region extending from distal of 11 to distal of 23, then two vertical incisions were given and a full-thickness trapezoidal mucoperiosteal flap was reflected. Large bony resorptive defect was present on the site [Figure 2]a. Complete curettage and enucleation of cyst was done. Root end of involved teeth was resected, and the retrograde filling was done with biodentine [Figure 2]b and [Figure 2]c. Closure of flap was done with 3-0 black silk suture following hemostasis [Figure 2]d and a posterior bite plane was given to the patient supporting the palatal mucosa as a stent [Figure 2]e and [Figure 2]f. Postoperative instructions were given, and the patient was put on capsule augmentin 625 mg and tablet combiflam thrice in a day for 5 days. The histopathology report confirmed the diagnosis of a radicular cyst. The patient was recalled at intervals of 1, 7 days 3, 6 months, and 1 year. When the patient was recalled after 3 months, he had no complaints of any pain or mobility in the teeth, his main concern was discolored 21. CBCT was taken, which showed the evidence of a mild reduction in size as compared to the preoperative CBCT scan signifying healing lesion. Hence, inside-outside nonvital bleaching was planned. Bleaching agent containing 37.5% hydrogen peroxide (Pola Office Plus, SDI, Australia), chemically activated without light and heat was used in the current procedure. Gutta-percha was removed 2 mm below the cementoenamel junction and GIC (GC Fuji Type 2, Japan) was placed to create cervical seal. Bleaching agent was placed inside the access cavity and on the labial surface of the crown w. r. t 21 after gingival barrier placement [Figure 2]g. After 10 min the bleaching agent was washed and removed with high volume suction [Figure 2]h. The next sitting was scheduled after a week. After two sittings, desired results were obtained [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d. The patient was kept on follow-up and a CBCT was taken again after a year which showed further reduction in the size of radiolucency from preoperative 15.9 mm ML × 11.7 mm AP × 12.1 mm SI to 10.1 mm ML × 9.5 mm AP × 8.7 mm superoinferiorly (SI) after a year [Figure 4].
Figure 1: (a) Intraoral image showing discolored tooth 21. (b) Intraoral image showing swelling on the palate with respect toto tooth 21, 22. (c) IOPA radiograph showing periapical radiolucency involving tooth 21, 22. (d) Cone-beam computed tomography image showing bony defect in axial, coronal and sagittal view

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Figure 2: (a) Full-thickness trapezoidal mucoperiosteal flap reflected revealing large bony resorptive defect. (b) IOPA radiograph showing biodentine retrograde filling with respect to tooth 21, 22 (c) Enucleated pathology transferred into formalin solution. (d) Flap sutured back into place. (e and f) Palatal stent given to the patient. (g) Intraoral image showing bleaching agent applied over labial surface of the crown after gingival barrier placement. (h) Results after the 1st sitting of inside/outside bleaching

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Figure 3: (a and b) Results after the 2nd sitting of inside/outside bleaching (c and d) Intraoral images comparing preoperative and postoperative images

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Figure 4: Cone-beam computed tomography taken after a year of follow-up showing considerable reduction in size of radiolucency

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   Discussion Top


The radicular cyst is the most frequent cystic lesion affecting human jaws, with a percentage ranging from 52% to 68%.[4] It is more commonly seen in males compared to females with a ratio of 1.6:1.[5] The anterior maxilla is more commonly involved in comparison to the mandible, which may be due to an increased probability of trauma in the anterior teeth.[6] The natural history begins with a nonvital tooth that remains in situ, long enough to develop chronic periapical pathosis.[7] The CBCT has an important value in radiographic examination in endodontics and diagnosis of periapical lesions. In this case report, the CBCT scan was advised to see the full extent of lesion and to check the proximity of lesion with vital structures since it was extensive. It showed perforation of the buccal cortex and palatal alveolar cortical plate, loss of cortical outline of the nasopalatine canal. Thinning and superior displacement of the nasal floor on the left side is seen. A fine-needle aspiration of the swelling revealed straw-colored fluid and various other features like the texture of swelling being soft and fluctuant, the association of nonvital teeth, extensive size of the lesion measured in CBCT lead to the provisional diagnosis of a radicular cyst which was later confirmed with biopsy. These kinds of cystic lesions can be managed either surgically or nonsurgically. There has been a gradual change in the attitude to the surgical treatment of periapical lesions. Some authors support that the immune system promotes repair and lesion might recede by the mechanism of apoptosis in cases of pseudocysts when the root canals of the associated teeth are made free of irritants.[8] However, in some cases depending on the type, size, and extent of the lesion, surgical management might be necessary for achieving success.[9],[10] In view of the clinical and radiographic signs found in this case, the decision of surgical management of the radicular cyst was taken. The surgical approach to cystic lesions of the jaws is either marsupialization or enucleation. The treatment of choice depends on various parameters such as size and localization of the lesion, availability of the patient for periodic drainage, bone integrity of the cystic wall and its proximity to vital structures. Mineral trioxide aggregate and Biodentine® are widely used as root-end filling materials. In the current case, the lesion was enucleated along with curettage, followed by apicoectomy and placement of Biodentine as root-end filling material. The absence of pain, regression of periapical radiolucency, recovery of tooth function, complete seal of radicular and coronal spaces are the attributes by which the prognosis of an endodontically treated tooth be evaluated over time.[11] The presence of pulpal hemorrhagic products is the most common cause of discoloration in nonvital teeth. It is thought that the discoloration is due to the accumulation of the breakdown products of hemoglobin or other haematin molecules from the pulp following trauma.[12] Discolored root-filled teeth can be successfully managed with the inside/outside bleaching technique. Bleaching gel is placed on the internal and external aspects of the discolored root-filled tooth. Of frequent concern to dentists is the possible association of cervical root resorption with nonvital bleaching. There are many benefits of using the inside/outside bleaching technique for nonvital cases in comparison to the external night-guard bleaching technique. The removal of the access cavity restoration allows the greater surface area to be bleached at a time when the agent is applied to the external and internal aspects of the discolored tooth.[3]


   Conclusion Top


In this clinical report, the radicular cyst was treated successfully using a multidisciplinary approach. Endodontic therapy, along with thorough chemomechanical preparation and filling of the canal space was followed by the enucleation surgery. Later on, discolored incisor was managed with inside/outside nonvital bleaching which is a rapid technique, and treatment time is shorter than the walking bleach technique so the contact time of the hydrogen peroxide with the peri-cemental tissues is reduced and the elimination of the foreign body holds the key to success the management of large radicular cysts.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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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.  Back to cited text no. 8
    
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Kadam NS, Ataide Ide N, Raghava P, Fernandes M, Hede R. Management of large radicular cyst by conservative surgical approach: A case report. J Clin Diagn Res 2014;8:239-41.  Back to cited text no. 9
    
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Diwan A, Bhagavaldas MC, Bagga V, Shetty A. Multidisciplinary approach in management of a large cystic lesion in anterior maxilla-A case report. J Clin Diagn Res 2015;9:ZD41-3.  Back to cited text no. 10
    
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Estrela C, Holland R, Estrela CR, Alencar AH, Sousa-Neto MD, Pécora JD. Characterization of successful root canal treatment. Braz Dent J 2014; 25:3-11.  Back to cited text no. 11
    
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Marin PD, Bartold PM, Heithersay GS. Tooth discolouration by blood: An in vitro histochemical study. Endod Dent Traumatol 1997;13:132-8.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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