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

1. Assistant Professor, Department of Oral and Maxillofacial Surgery, Yenepoya Dental College, Mangaluru, Karnataka, India. 2. Postgraduate Student, Department of Paediatric and Preventive Dentistry, Yenepoya Dental College, Mangaluru, Karnataka, India. 3. Professor, Department of Oral and Maxillofacial Surgery, Yenepoya Dental College, Mangaluru, Karnataka, India. 4. Professor and Head, Department of Paediatric and Preventive Dentistry, Yenepoya Dental College, Mangaluru, Karnataka, India.

Abstract

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.

Decompression, Mandible, Mixed dentition, Odontogenic cyst, Periapical

Discussion

In the case presented, there was a complete enclosure of the unerupted tooth by the cystic lining. Decompression was pursued over enucleation to avoid damage to the permanent tooth. Essentially, the patency of the cystic lesion is maintained by either tightly packing gauze into the cystic cavity or by using a silicone drain or decompression tube, necessitating frequent dressing changes and cystic cavity irrigation performed by the clinician. Numerous authors have developed different kinds of catheters designed for use as custom-made decompression tubes, utilising materials such as intravenous lines, nasal cannulas, paediatric anaesthesia tubes, plastic dental syringes, urethral catheters, and thermoplastic resin to facilitate drainage (1). Oliveros-Lopez L et al., in their study, successfully employed a decompression tube that passed through a surgically induced bony window positioned over the cystic wall (2). In the case series by De Carvalho IKF and Luna AHB, they employed a transalveolar silicone drain to facilitate the decompression of dentigerous cysts during the mixed dentition period (3). Nawaz MS et al., used a multipurpose acrylic splint for the rehabilitation of radicular cysts during the mixed dentition period (4). Weimer SJ et al., used a modified partial denture as a decompression device (5). The difference in the case presented is the modified surgical stent. The removable appliance used in this case had an acrylic extension along with a clasp on either side. This design facilitated a snug fit into the space without any mobility, hence reducing the chance of swallowing/aspiration. Due to the increased number of visits and to increase the compliance of the patient towards treatment, an appliance made of self-cure acrylic was designed in such a way that would help the patient irrigate the socket with an easy path of insertion and removal while maintaining the space during the treatment period. Apart from these advantages, wound patency was also maintained. The patient was able to maintain good oral hygiene, and food lodgement was reduced. The disadvantage of this method was its function in mastication and adaptability of the appliance as cortical plate obliteration reduced. The patient gave good feedback on the appliance.

A modified non functional removable stent with self-irrigation is an effective method to function as a Marsupialisation stent and space maintainer in the mixed dentition.

Acknowledgement

The authors would like to thank Dr. Riaz Abdulla, Dr. Vishnudas Prabhu, Dr. Eva Rachel Koshy, Department of Oral Pathology, Yenepoya Dental College, for their help in obtaining the images of histopathological slide.

DOI and Others

DOI: 10.7860/JCDR/2024/70702.19775

Date of Submission: Mar 20, 2024
Date of Peer Review: May 07, 2024
Date of Acceptance: Jun 19, 2024
Date of Publishing: Aug 01, 2024

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

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ETYMOLOGY: Author Origin

EMENDATIONS: 6