RARE PRESENTATION OF RADICULAR CYST WITH REVIEW OF THE LITERATURE

Abstract

Clinical Presentation A 61-year-old male with a noncontributory medical history and a facial swelling of 1 week’s duration reported to his local emergency room. The physician prescribed penicillin and made a dental referral. The dentist obtained a pantomograph and, upon visualization of the lesions, referred the patient to the University of Florida Emergency Department, where cone beam computed tomography (CBCT) was performed. The pantomograph illustrated 2 well-localized, partially corticated, radiolucent entities, which appeared hydraulic in nature, in the maxilla and a well-defined, corticated, mixed-density entity, which appeared hydraulic in nature, in the right parasymphyseal region of the mandible. Evaluation of the CBCT scan affirmed the maxillary lesions to be consistent with radicular cysts. The mandibular lesion was well defined, expansile, corticated, and unilocular and was predominantly radiolucent but with internal radiopaque entities. There was thinning of the mandibular buccal and lingual cortices, with possible disruption of the lingual cortex. Differential Diagnosis Calcifying odontogenic cyst (COC), ameloblastic fibro-odontoma, calcifying epithelial odontogenic tumor (CEOT), and ossifying fibroma were considered in the differential diagnosis. Diagnosis and Management The histologic investigation determined all 3 lesions to be radicular cysts. The radiopaque entities seen in the mandibular lesion were identified as cholesterol granulomas with multiple foci of calcification. Management included extraction of tooth #29 and surgical removal of all 3 radicular cysts. Discussion Radicular cysts with internal calcifications have been described in histopathologic evaluations but rarely in radiographic evaluations of radicular cysts. The differential diagnosis of COC was believed to be the most likely diagnosis because of its variable presentation. CEOT was not considered because of the advanced age of the patient but could not be ruled out. Similarly, the differential diagnosis of an ameloblastic fibro-odontoma was unlikely because it is typically seen in a much younger age group, but was included in the differential diagnosis. Radicular cyst was not initially considered in the differential diagnosis because of the presence of internal radiopaque entities. This case reinforces the importance of correlating clinical findings with radiographic findings. Even though radicular cysts with internal calcifications are rare and not often documented in the literature, under the right circumstances and with the aid of proper clinical information, a radicular cyst should be considered in the differential diagnosis of a lesion with internal calcifications. The proper diagnosis of radicular cysts may lead to a more conservative treatment approach, such as endodontic therapy vs enucleation, greatly improving the patient’s comfort and prognosis. A 61-year-old male with a noncontributory medical history and a facial swelling of 1 week’s duration reported to his local emergency room. The physician prescribed penicillin and made a dental referral. The dentist obtained a pantomograph and, upon visualization of the lesions, referred the patient to the University of Florida Emergency Department, where cone beam computed tomography (CBCT) was performed. The pantomograph illustrated 2 well-localized, partially corticated, radiolucent entities, which appeared hydraulic in nature, in the maxilla and a well-defined, corticated, mixed-density entity, which appeared hydraulic in nature, in the right parasymphyseal region of the mandible. Evaluation of the CBCT scan affirmed the maxillary lesions to be consistent with radicular cysts. The mandibular lesion was well defined, expansile, corticated, and unilocular and was predominantly radiolucent but with internal radiopaque entities. There was thinning of the mandibular buccal and lingual cortices, with possible disruption of the lingual cortex. Calcifying odontogenic cyst (COC), ameloblastic fibro-odontoma, calcifying epithelial odontogenic tumor (CEOT), and ossifying fibroma were considered in the differential diagnosis. The histologic investigation determined all 3 lesions to be radicular cysts. The radiopaque entities seen in the mandibular lesion were identified as cholesterol granulomas with multiple foci of calcification. Management included extraction of tooth #29 and surgical removal of all 3 radicular cysts. Radicular cysts with internal calcifications have been described in histopathologic evaluations but rarely in radiographic evaluations of radicular cysts. The differential diagnosis of COC was believed to be the most likely diagnosis because of its variable presentation. CEOT was not considered because of the advanced age of the patient but could not be ruled out. Similarly, the differential diagnosis of an ameloblastic fibro-odontoma was unlikely because it is typically seen in a much younger age group, but was included in the differential diagnosis. Radicular cyst was not initially considered in the differential diagnosis because of the presence of internal radiopaque entities. This case reinforces the importance of correlating clinical findings with radiographic findings. Even though radicular cysts with internal calcifications are rare and not often documented in the literature, under the right circumstances and with the aid of proper clinical information, a radicular cyst should be considered in the differential diagnosis of a lesion with internal calcifications. The proper diagnosis of radicular cysts may lead to a more conservative treatment approach, such as endodontic therapy vs enucleation, greatly improving the patient’s comfort and prognosis.