Use of Modified Acrylic Stent in the Management of Radicular Cyst in a Paediatric Patient: Images in Medicine ZJ01-ZJ03

Correspondence
Dr. Prithi Shenoy,
Department of Paediatric and Preventive Dentistry, Yenepoya Dental College, University Road, Derlakatte, Mangaluru-575018, Karnataka, India.
E-mail: prithimds@gmail.com

A nine-year-old female patient reported to the Department of Paediatric and Preventive Dentistry with a chief complaint of pain in the lower left back tooth region for two months. The patient experienced dull achy pain, which aggravated over two weeks and gradually progressed. The patient reported a history of nocturnal pain and previous dental treatment in the area of concern.

On extraoral examination, facial asymmetry was seen (Table/Fig 1). Upon inspection, mild diffuse swelling 2×3 cm in size was noted on the left lower third of the face, extending across the lower border of the mandible. On palpation, an oval swelling, firm in consistency with a smooth surface and a diffuse edge, was noted in the lower border of the mandible. It was non compressible, non reducible, tender, and febrile.

Upon intraoral examination, buccal expansion with vestibular obliteration was noted (Table/Fig 2). On palpation, diffuse bony hard swelling was noted between 34 to 36.

On the panoramic radiograph (Table/Fig 3), a well-defined unilocular radiolucency with a sclerotic border was noted, extending anteroposteriorly from the distal aspect of 33 up to the mesial aspect of the distal root of 36. Inferiorly, the radiolucency was associated with impacted tooth 35. The root formation appeared to be incomplete. Superiorly, with respect to 75, an ill-defined radiolucency involving pulp with external root resorption was noted. Medial displacement of the root of 34 was noted.

On Cone Beam Computed Tomography (CBCT) examination, inferior displacement of the inferior alveolar nerve canal with decortication of the roof was noted (Table/Fig 4). Expansion of the buccal cortical plate with extreme thinning and mild expansion was noted at the lingual cortical plate (Table/Fig 5),(Table/Fig 6),(Table/Fig 7),(Table/Fig 8).

The differential diagnosis based on clinical examination was radicular cyst or dentigerous cyst. Based on the diagnosis made, treatment options were enucleation or a two-staged procedure- Marsupialisation followed by enucleation and decompression. However, as the patient was in the mixed dentition phase, Marsupialisation and decompression with cystic enucleation was considered the most beneficial treatment.

The mucoperiosteal flap was reflected under local anaesthesia. Retained deciduous 75 was extracted. An incision was made at the site of the extracted primary tooth to unroof the cystic lining (Table/Fig 9)a. The cystic fluid was then evacuated, and the cavity was irrigated with normal saline. The margin of the cystic lining was sutured to the adjacent gingival margin of the wound (Table/Fig 9)b.

The patency of the cystic lesion within the extraction socket was preserved by employing a customised appliance. This adaptation was designed to enhance the child’s comfort and minimise the need for frequent follow-ups. A removable appliance was fabricated using acrylic resin and C clasps on 34 and 36 for retention and a projection into the cystic cavity, which would help in preventing food seepage and help the patient avoid frequent multiple visits to the hospital (Table/Fig 10)a,b,(Table/Fig 11)a,b. The patient’s parents were taught to irrigate the cavity thrice a day by removing the appliance and irrigating with copious amounts of diluted betadine solution to reduce surgical site infection. Hence, 35 was retained. The patient reported to the hospital once every 10 days for two months. Later, the visit was reduced to once a month for radiographic assessment and appliance trimming. Radiographically, 2-3 mm of the eruption of 35 was noted in comparison to the first serial radiograph. This was a much lesser frequency compared to alternate-day visits required for the medicated gauze packing method. Once 35 was closer to eruption (Nollas stage 8), the patient discontinued wearing the appliance, and cystic enucleation was planned. The patient was recalled one month later for cystic enucleation under local anaesthesia. The mucoperiosteal flap was reflected from the 1st molar to the canine, the cystic cavity was approached from the healing socket, and the cystic lining was removed in toto and sent for biopsy (Table/Fig 12)a-d. The histopathological feature showed an arcading pattern of non keratinised stratified squamous epithelium with chronic inflammatory cell infiltration, confirming the diagnosis as a radicular cyst.

A series of radiographs were used to monitor the patient for a total of six months (Table/Fig 13) until the first permanent premolar 35 was extruded orthodontically.

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