Median mandibular lateral periodontal cyst

Median mandibular lateral periodontal cyst Peter hf. DiFiore, D.D.S., M.S., Lieutenant Colonel, DC, USA,* and Gary R. Hartivell, D.D.S., M.S., Colonel, DC, USA,** Wuerzburg, West Germany, and Fort Gordon, Ga. US.

ARMY

DENTAL

ACTIVITY

The lateral periodontal cyst is a developmental odontogenic cyst associated with the of teeth. It is treated by surgical enucleation and diagnosed on the basis of clinical, histologic findings. This article is a case report of the surgical treatment of a lateral unique mandibular midline location. The preoperative history and postoperative recall an 8-year period. (ORAL SURC. ORAL MED. ORAL PATHOL. 1987;63:545-50)

ase studies describing the clinical, radiographic, C and histologic features of the lateral periodontal cyst have been reported in the literature.1-‘2 Authors have generally defined lateral periodontal cysts as developmental odontogenic cysts located along the lateral root surfaces of teeth and directly associated with the periodontal membrane. 4.8v9,’ ’ This clinically asymptomatic lesion is usually detected on routine radiographic examination as a well-circumscribed, round to oval radiolucency on the lateral aspect of the roots of vital teeth.2-5~8*9~“-‘3The highest incidence of this cyst occurs in the fourth and fifth decades of life, and it is most frequently located in the mandibular premolar and canine areas.2m5v 8*9.‘l-l3 The cause of the lateral periodontal cyst has not been clearly established. Many theories have been proposed concerning its pathogenesis. The most common explanation is that it arises from the epithelial cell rests of Malassez in the periodontal membrane.4*‘4* I5 This is a logical conclusion since, both anatomically and histologically, this lesion is closely associated with the periodontal membrane.4 However, another explanation is that the lateral periodontal cyst is a gingival cyst that has eroded through the cortical plate of the alveolar bone and has come in contact with the roots of the teeth.7, 8*16-18 The gingiThe opinions expressed herein are those of the authors and are not to be construed as those of the Department of the Army or the Department of Defense. *Chief of Endodontics. **Consultant to the Surgeon General in Endodontics, Director of the Endodontic Residency Program

lateral root surfaces radiographic, and periodontal cyst in a examinations cover

val cyst is most generally considered to arise from epithelial cell remnants of the dental lamina, the rests of Serres.7* 8,I73I8 To support the common histogenesis of the lateral periodontal and gingival cysts, both have been shown histologically to contain dental lamina epithelial clear cells in their linings and capsule walls.‘* Authors have also suggested other theories for the pathogenesis of the lateral periodontal cyst, including that it is of reduced enamel epithelial origin developing as a dentigerous cyst that takes a position lateral to the root after the tooth has erupted,9 or that it arises from the enamel organ of a supernumerary tooth as a primordial cyst.7s” The clinical course of the lateral periodontal cyst is one of insidiousness and slow growth.7* ‘I* 13.I9 It can cause cortical bone expansion, perforation, and root displacement.7, ‘OS‘I, I39I9 The neoplastic potential of the lateral periodontal cyst has been discussed on the basis of its capability for aggressive growth and its common predilection with the adenoameloblastoma for the mandibular canine-premolar area.13 Also, the presence of clear cell odontogenic epithelium in lateral periodontal cysts and the propensity of these cells for neoplastic changes have been correlated with the development of an ameloblastoma in the mandibular premolar region.8 Most significant was a case report that found squamous cell carcinomatous transformations within the stratified squamous epithelial lining of a lateral periodontal cyst.20 In terms of periodontal diagnosis and treatment, it has been pointed out that the lateral periodontal cyst is implicated in the cause of isolated periodontal defects.21 Treatment of the lateral periodontal cyst 545

546

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and Hartwell

May,

Fig.

1. Prior periapical

Fig. 2. Preoperative angulation.

periapical

radiographs.

radiographs.

A,

A,

consists of surgical enucleation and biopsy, with conservation of the surrounding alveolar bone and adjacent teeth.le3- 7-I47*O The postoperative healing usually progresses to eventual bony regeneration in the pathologic defect with no recurrence and a good prognosis.‘-” I37I9 The following is a case report of the surgical management of a lateral periodontal cyst occurring in the midline of the mandible between the roots of the central incisor teeth.

1987

Four years before. B, Two years before.

Normal

CASE

angulation.

B,

Left

angulation.

C, Right

REPORT

A 52-year-old man was referred to the endodontic section of a U. S. Army dental clinic for examination, diagnosis, and treatment of a mandibular midline radiolucency located between the roots of the central incisor teeth. No substantial findings were reported on the medical history, and the patient was considered in good general health. Four years earlier, the patient reported a chief complaint of sensitivity, numbness, and altered sensation in the mandibular central incisor area. There was no

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3. Surgical treatment. A, Preoperative photograph showing sinus track with suppurative exudate. B, Mucoperiosteum reflected, exposing lesion within its bony crypt. C, Lesion enucleated. D, Enucleated lesion. Fig.

history of trauma. The radiograph taken at that time showed no radiolucency, and another taken 2 years later still showed no radiolucency. On clinical examination, a sinus tract was present at the junction of the labial alveolar mucosa and the attached gingivae of the central incisors. A suppurative exudate could be expressed from the sinus tract orifice. Palpation of the alveolar mucosa and percussion of the teeth elicited no pain, sensitivity, or discomfort. The gingivae, although receded, were firm, were well attached, and had no periodontal pockets. The teeth were responsive to stimulation with ice and to the electric pulp tester. The radiograph revealed a well-circumscribed pear-shaped radiolucency directly in the midline between the roots of the mandibular central incisors. Periapical radiographs angulated from the left and right demonstrated that the apical periodontal membranes and bony laminae were intact and normal. The pulp chambers appeared obliterated, but the pulp canals were clearly visible. The periodontal bone showed horizontal recession. Local anesthetics were administered by bilateral mandibular conduction and supraperiosteal infiltration of the mandibular incisor teeth. Four 1.8 ml Carpules of 2% lidocaine with 1: 100,000 epinephrine were injected. A full-thickness mucoperiosteal vertical flap, extending from bilateral vertical incisions mesial to the canine teeth, was reflected. A well-circumscribed 0.8 X 0.6 X 0.6 cm oval lesion, not covered by bone, was totally enucleated from its bony crypt within the alveolar process between the mesial root surfaces of the mandibular incisor teeth. The lesion did not involve the apices of the teeth. The enucleated lesion was then placed in formalin solution for biopsy. The

bony crypt was curetted and irrigated with sterile normal saline solution. The mucoperiosteum was repositioned and sutured with seven interrupted 3-O silk thread sutures. One week after the surgery, the sutures were removed. Postsurgical examinations 1 and 2 months later revealed good healing of the alveolar mucosa, periosteum, and gingival attachment. There was no sinus tract and the teeth were asymptomatic and responsive to stimulation with ice and the electric pulp tester. These clinical findings were consistently the same at the 6-month and l-, 2-, and 3-year recall examinations. In addition, the periapical radiographs taken at these recall examinations showed progressive to complete bony regeneration of the pathologic defect (Figs. 1 to 6). HISTOPATHOLOGY

Histologically, lateral periodontal cysts have a connective tissue wall that is usually free of inflammation,4~8~9~ I’ and frequently they have islands of odontogenic clear epithelial cell rosettes. ‘a9 Numerous types of epithelial linings of lateral periodontal cysts have been observed. These cysts can have a keratinized and nonkeratinized stratified squamous epithelium, a clear odontogenic epithelium, a compressed cuboidal epithelium,s a squamous or cuboidal epithelium with plaques of clear epithelial cells,9 a thick, loosely arranged proliferative epithelium, a thin epithelium without rete pegs, and a cuboidal epithelium with parakeratosis and orthokeratosis.” Microscopic examination of the sectioned specimen in this case study revealed a cystic cavity lined with nonkeratinized hyperplastic stratified squamous epithelium, with anastomosing bands and rete pegs of proliferative epitheli-

548 DiFiore and Hartwell

Oral Surg. May, 1987

4. Histopathology.A, Longitudinally sectionedcyst. (Magnification, X5.) B, Fibroustissuecapsule. (Magnification, x20.) C, Epithelial lining. (Magnification, x20.) D, Proliferative epithelium. (Magnification, x70) E, Infiltrated areolar tissue. (Magnification, X150.) F, Epithelial cord. (Magnification, X‘l50.)

Fig.

Fig.

5. Recall clinical photographs.A, Six monthsafter surgery. B, One year after surgery.

DISCUSSION

al cells. An edematoushemorrhagic areolar connective tissue, with a chronic inflammatory cell infiltrate and polymorphonuclearleukocytes, was present beneath the epithelial lining. A fibrousconnectivetissuecapsulecomposedof circumferentially arranged bundlesof collagen fibers formed the peripheralwall of the lesion.

In view of the direct mandibular midline location of the cyst in this case study, part of a differential diagnosis would be a median mandibular cyst. The median mandibular cyst is considered a developmental cyst arising from fissural epithelial remnants

Median mandibular lateral periodontal cyst

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Fig.

6. Recall periapical

radiographs.

549

A, Six months. B, One year. C, Two years. D, Three years.

within the mandibular symphysis. However, the existence of these epithelial remnants is uncertain, and therefore the median mandibular cyst as a clinical entity could merely be the midline expression of some other type of cyst. Another consideration is that this cyst was an odontogenic primordial cyst arising from the primordium of a midline supernumerary tooth. However, this is highly unlikely, since mandibular midline supernumerary teeth are extremely rare and because the primordial cyst forms early in life, whereas this cyst is documented as developing late in life. Although this cyst showed a chronic inflammatory

cell and polymorphonuclear leukocyte infiltrate, it was not of inflammatory origin but, rather, became secondarily inflammed after sinus tract formation and communication with the oral cavity. This conclusion is supported by the clinical examination, which established that the dental pulps of the incisor teeth were vital and that the periodontium was well attached with no gingival inflammation or periodontal pocket formation. In addition, postsurgical recall examination up to 3 years later showed vital teeth, healthy periodontium, and bone regeneration in the pathologic defect. The possibility exists that this lesion was a midline

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gingival cyst that eroded the labial cortical bone and the alveolar bone between the central incisor roots. However, on surgical reflection of the mucoperiosteum, this cyst was located directly under the alveolar mucosa, well below the gingiva, and more apically positioned between the roots of the teeth. Furthermore, this cyst was closely associated with the periodontal membranes of the mesial root surfaces of the central incisor teeth, which suggests a periodontal membrane origin.

Oral May,

8.

9. IO. 11.

12.

CONCLUSIONS

13.

The mandibular midline is an unusual location for the lateral periodontal cyst. The diagnosis of a lateral periodontal cyst is made after evaluation of the clinical, radiographic, and histologic findings. The treatment of the lateral periodontal cyst is surgical enucleation and biopsy, with conservation of the surrounding tissues. Since the cause of the lateral periodontal cyst is uncertain, a more appropriate name, based solely on its location and not on its origin, would be periradicular cyst.

14.

REFERENCES

19.

I. Mezrow RR: A case report of a paradental cyst. J Am Dent Assoc 41: 77-78, 1950. 2. Cross WC: Lateral periodontal cyst: Report of a case J Periodontol 25: 287-289, 1954. 3. Holder TD, Kunkel PW, Jr: Case report of a periodontal cyst. ORAL SURG ORAL MED ORAL PATHOL 11: 150-I 54, 1958. 4. Standish SM, Shafer WG: The lateral periodontal cyst. J Periodontol 29: 27-33, 1958. 5. Harless CF, Jr: Lateral periodontal cyst: Report of two cases. ORAL SURC ORAL MED ORAL PATHOL 20: 684-689, 1965. 6. Howell RA: Two cases of lateral periodontal cyst. ORAL SURG ORAL MED ORAL PATHOL 23: 183-188, 1967. 7. Moskow BS, Siegel K, Zigarelli EV, Kutscher AH, Rothen-

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berg F: Gingival and lateral periodontal cysts. J Periodontol 41: 249-260, 1970. Gold L, Sliwkowski AS: Lateral periodontal cyst: A clinical and histological study. Trans Int Conf Oral Surg 4: 85-89. 1973. Shear M, Pinburg JJ: Microscopic features of the lateral periodontal cyst. Stand J Dent Res 83: 103-l 10, 1975. Lederman DA: Lateral periodontal cyst: Report of a case. J Oral Med 30: 62-63, 1975. Fantasia JE: Lateral periodontal cyst: An analysis of forty-six cases. ORAL SURG ORAL MED ORAI. PATHOI. 48: 237-243. 1979. Krier PW: Lateral periodontal cyst. ORAL SURO ORAL MED ORAL PATHOL 49: 475, 1980. Rickles NH, Everett FG: Gingival and lateral periodontal cysts: Report of two cases. Paradontologie 14: 41-45, 1960. Summers GW: Jaw cysts: Diagnosis and treatment. Head Neck Surg 1: 243-256, 1979. Regezi JA, Courtney RM, Batsakis JG: The pathology of head and neck tumors: Cysts of the jaws. Part 12. Head Neck Surg 4: 48-57, 1981. Bhaskar SN, Laskin DM: Gingival cysts: Report of three cases, ORAL SURC ORAL MED ORAL PATHOL 8: 803-807, 1955. Gardner DG, Sapp DJ, Wysocki GP: Odontogenic and fissural cysts of the-jaws. Pathol Annu 13: 177-200, 1978. Wysocki GP, Brannon RB, Gardner DG, Sapp PG: Histogenesis of the lateral periodontal cyst and the gingival cyst of the adult. ORAL SURG ORAL MED ORAL PATHOL 50: 327-334, 1980. Degering CL Radiography of a lateral periodontal cyst. ORAL. SURG ORAL MED ORAL PATHOL 32: 498-501. 1971. Baker RD, D’Onofrio ED, Corio RL, Crawford BE, Terry BC: Squamous cell carcinoma arising in a lateral periodontal cyst. ORAL SURG ORAL MED ORAL PATHOL 47: 495-499, 1979. Filipowicz FJ, Page DC: The lateral periodontal cyst and isolated periodontal defects. J Periodontol 52: 145-l 5 1, 1982.

Reprint requests to: Lt. Col. Peter M. DiFiore U. S. Army Dental Activity Fort Bragg, NC 28307-5000