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 Table of Contents 
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 4  |  Page : 2111-2113  

Multiple radiolucencies in the mandible: A diagnostic dilemma


Department of Oral and Maxillofacial Surgery, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India

Date of Submission21-Dec-2019
Date of Decision28-Dec-2019
Date of Acceptance20-Feb-2020
Date of Web Publication30-Apr-2020

Correspondence Address:
Dr. Susmitha Madishetti
Sri Sai College of Dental Surgery, Vikarabad - 501 102, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_1204_19

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  Abstract 


Diagnosis and treatment planning of maxillofacial pathologies is an art. It requires careful evaluation and correlation of clinical presentation and radiologic investigations. When the pathology concerned is an intraosseous lesion, the radiographic findings assume a significantly more important role. While carrying out the radiographic assessment, we rely on typical findings regarding the number, location, and appearance of radiolucent areas which point towards certain types of pathologies. Whenever these findings are atypical or at variance with the clinical presentation, it creates a diagnostic dilemma for the clinician. We report a case of a 34-year-old man who presented with a simple clinical history but multiple radiolucencies on the radiograph.

Keywords: Dentigerous cyst, multiple radiolucencies, odontogenic cyst, radicular cyst


How to cite this article:
Madishetti S, Tiwari PK, Sinha R, Uppada UK, Banavath S, Tiwari RV. Multiple radiolucencies in the mandible: A diagnostic dilemma. J Family Med Prim Care 2020;9:2111-3

How to cite this URL:
Madishetti S, Tiwari PK, Sinha R, Uppada UK, Banavath S, Tiwari RV. Multiple radiolucencies in the mandible: A diagnostic dilemma. J Family Med Prim Care [serial online] 2020 [cited 2021 Feb 26];9:2111-3. Available from: https://www.jfmpc.com/text.asp?2020/9/4/2111/283410




  Introduction Top


The jaws are host to a wide variety of cysts and neoplasms, due in large part to the tissues involved in tooth formation.[1],[2] Establishing a diagnosis is especially challenging if the clinical presentation and radiographic appearance are unusual. Multiple cystic lesions in the jaws are usually considered as aggressive lesions.[3] This report deals with a case of multiple cysts bilaterally in the mandible.


  Case History Top


A 34-year-old male reported with a complaint of pain and pus discharge from a 5-month-old extraction site of the decayed left mandibular first molar. After the extraction, the pus discharge continued unabated and the patient was referred to us. There was no relevant medical or family history. Extraoral examination showed no gross facial asymmetry or other significant findings. Intraorally a missing left mandibular 1st molar and partially erupted right mandibular canine was seen. No cortical expansion, displacement of adjacent teeth, or involvement of adjoining soft tissues was noted. History and clinical findings pointed towards a radicular cyst missed during extraction.

Orthopantomogram was advised and it showed two distinct radiolucencies. Large unilocular radiolucency with well-defined border extending from periapical region of the mesial root of the left mandibular second molar to canine with a radiopaque septum seen at the 1st molar. No interference with adjacent teeth or neurovascular bundle was seen. Unilocular radiolucency with a well-defined border on the right side associated with a partially erupted canine. No displacement or resorption of adjoining teeth seen. Computed tomography (CT) scan was used to confirm the extent and characteristics of these lesions [Figure 1]. Radiographically, there appeared to be two separate lesions with slightly more aggressive characteristics in the posterior mandible. Due to a large radiolucent lesion spreading along the marrow cavity without causing significant cortical expansion along with a separate radiolucent lesion on the other side, a diagnosis of an aggressive odontogenic lesion like OKC was made which may have been secondarily infected from the decayed tooth. Incisional biopsy was performed from the lesion in the left mandible and the histological report was suggestive of a residual cyst. Enucleation of both lesions was planned and all the teeth associated with them underwent root canal treatment. Under general anesthesia, an intraoral vestibular incision was used to approach and enucleate both the lesions. The surgically excised lesion of the left side was about 2 × 3 cm in size and of the right side was 1 × 3 cm in size [Figure 2]. Histopathological examination of the surgical specimen of left side showed nonkeratinized stratified squamous epithelial lining with inflammatory cell infiltration, suggestive of radicular cysts while specimen from the right side showed a cystic lumen, lining of 2–3 cell layered thickness resembling the reduced enamel epithelium, capsule, and connective tissue including few dentinoid like area and odontogenic cell rest, suggestive of dentigerous cyst [Figure 3].
Figure 1: Showing the extending from the periapical region of the mesial root of the mandibular left first molar to mandibular left canine and another well-defined unilocular radiolucency with a well-defined border was seen on the right side of the mandible, which is associated with the periapical region of partially erupted mandibular right canine and lateral incisor. a) OPG b) Axial section of CT

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Figure 2: Intraoperative picture of cystic enucleation

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Figure 3: (a) Histopathological examination of the surgical specimen of the left side showed non-keratinized stratified squamous epithelial lining with inflammatory cell infiltration, suggested as radicular cysts on the left side. (b) The surgical specimen of the right side showed a cystic lumen, the lining of 2–3 cell layered thickness resembling the reduced enamel epithelium, capsule, and connective tissue showed few dentinoid like area and odontogenic cell rest, suggested as a dentigerous cyst on the right side

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  Discussion Top


The cyst is defined as "a pathological cavity having a fluid, semifluid, or gaseous content and which is not created by the accumulation of pus.[3] The physical signs and symptoms of a jaw cyst depend on dimensions and biological characteristics of the lesion. Smaller cysts are usually incidental diagnoses upon radiographic examination and have no clinical manifestations.[4] There are many variations to the classical presentation of a cyst depending on the type of cyst, its biological characteristics, location, and degree of bone destruction and expansion.[5] In our case, the patient complained of decayed tooth and continuous discharge after extraction usually common in the radicular or residual cyst. Due to the discharge of cystic content pressure and pain were relieved. Oral swelling varies wildly depending on the amount and pattern of bone loss. Swelling may go from the hard bony expansion of buccal cortex leading to eggshell crackling followed by a soft fluctuant area of bone perforation due to progressive cortical thinning. But there is also a possibility of secondary infection of a preexisting lesion due to decayed tooth. This was a viable possibility because OPG showed secondary radiolucency in the anterior mandible. Another factor to consider is that radicular cyst is relatively uncommon in the posterior mandible but the lesion in our case appeared to have a more aggressive character than usually associated with radicular cysts. The posterior mandible is a common site for OKC which usually present as benign unilocular or multilocular radiolucency with smooth borders spreading along the marrow cavity with nil to the minimal expansion of buccal cortex. A significant number of OKC present as multiple jaw cyst without any associated syndrome. Sometimes these present a more aggressive pattern showing bicortical expansion and displacement of neurovascular bundle and tooth.[6] Another unilocular radiolucency with sclerotic border associated with the tooth is seen in anterior mandible usually indicative of dentigerous cyst.[7] The diagnostic dilemma, in this case, arises from the presence of two atypical lesions simultaneously. Literature reviews that bilateral occurrence of jaw cysts is an uncommon phenomenon. Among the jaw cysts, OKC showed most common bilateral occurrence followed by the dentigerous cyst.[8] An extensive search identified only 21 cases of bilateral dentigerous cysts in non-syndromic patients.[4] Reported cases of bilateral radicular cyst in mandible at the posterior region are also present in literature.[9],[10] A rare case of bilateral orthokeratinized odontogenic cyst in the mandible is also reported.[8] An unusual case of multiple cysts in maxilla where the hereditary amelogenesis imperfecta caused the pulpal exposure and led to the formation of multiple radicular cysts was also reported.[11] Any lesion related to the maxillofacial region requires prime intention and primary care as such lesions if undiagnosed or untreated properly can lead to various serious manifestations of the oral and maxillofacial region. In some circumstances, these can be fatal, so primary care is of utmost importance.


  Conclusion Top


Many such reports are available documenting multiple benign odontogenic cysts in the same jaw. However, we have not yet come across non-syndromic cases having more than one type of cyst in the same jaw as in this patient. What also makes this case remarkable is that both the cysts are in areas which are not the most common ones for these respective lesions. Such atypical clinical and radiological finding can sometimes cause a great dilemma for the clinician in diagnosis and treatment planning of odontogenic lesions, which are already difficult to definitively diagnose without histopathological examination in a large number of cases. This case report aims to reinforce the importance of accurate radiographic analysis as well as clinical correlation to arrive at an accurate diagnosis to allow optimal treatment planning of apparently benign lesions of jaw.

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

1.
Ahire MS, Tupkari JV, Chettiankandy TJ, Thakur A, Agrawal RR. Odontogenic tumors: A 35-year retrospective study of 250 cases in an Indian (Maharashtra) teaching institute. Indian J Cancer 2018;55:265-72.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Regezi J. Odontogenic cysts, odontogenic tumors, fibroosseous, and giant cell lesions of the jaws. Mod Pathol 2002;15:331-41.  Back to cited text no. 2
    
3.
Noda A, Abe M, Shinozaki-Ushiku A, Ohata Y, Zong L, Abe T, et al. A bilocular radicular cyst in the mandible with tooth structure components inside. Case Rep Dent 2019;2019:4. Article ID 6245808.  Back to cited text no. 3
    
4.
Pant B, Carvalho K, Dhupar A, Spadigam A. Bilateral nonsyndromic dentigerous cyst in a 10-year-old child: A case report and literature review. Int J App Basic Med Res 2019;9:58-61.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Nyimi BF, Zhao Y, Liu B. The Changing landscape in treatment of cystic lesions of the jaws. J Int Soc Prevent Communit Dent 2019;9:328-37.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Hadziabdic N, Dzinovic E, Udovicic-Gagula D, Sulejmanagic N, Osmanovic A, Halilovic S, et al. Nonsyndromic examples of odontogenic keratocysts: Presentation of interesting cases with a literature review. Case Rep Dent 2019;2019:12. Article ID 9498202.  Back to cited text no. 6
    
7.
Zerrin E, Husniye DK, Peruze C. Dentigerous cysts of the jaws: Clinical and radiological findings of 18 cases. J Oral Maxillofac Radiol 2014;2:77-81.  Back to cited text no. 7
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8.
Uddin N, Zubair M, Abdul-Ghafar J, Khan ZU, Ahmad Z. Orthokeratinized odontogenic cyst (OOC): Clinicopathological and radiological features of a series of 10 cases. Diagn Pathol 2019;14:28.  Back to cited text no. 8
    
9.
Aparna PV, Ramasamy S, Sankari SL, Massillamani F, Priyadharshini A. Bilateral radicular cyst of the mandible: A rare case report. SRM J Res Dent Sci 2018;9:37-9.  Back to cited text no. 9
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10.
Bava FA, Umar D, Bahseer B, Baroudi K. Bilateral radicular cyst in mandible: An unusual case report. J Int Oral Health 2015;7:61-3.  Back to cited text no. 10
    
11.
Tripathy M, Srivastava S, Chethan BR, Dsilva J. Multiple cysts of jaw and amelogenesis imperfecta – An unusual case report. Int J Oral Health Sci 2015;5:133-9.  Back to cited text no. 11
  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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