PMC6644300_01
Preoperative clinical photograph and radiographs showing (a) circumscribed swelling in the attached gingiva in between the left mandibular canine (33) and premolar (34); (b) three-dimensional reconstructed cone beam computed tomography image of left mandible showing cystic lesion between roots of teeth 33 and 34, along with loss of buccal and lingual cortices; and (c) orthopantomograph showing well-circumscribed radiolucency with a sclerotic border in between roots of teeth 33 and 34, along with displacement of the roots.
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Upon clinical examination, a well-circumscribed and fluctuant swelling, measuring about 9-12 mm in diameter, was observed at the junction of the buccal attached and free gingival margins in between the left mandibular canine (33) and premolar tooth (34) (Figure 1). Cone beam computed tomography (CBCT) of the region of interest revealed a cystic lesion between the roots of the left mandibular canine and premolar, along with resorption of both the buccal and lingual cortical plates (Figure 1).
Intraoperative clinical photographs showing (a) mucoperiosteal flap elevation and visualization of the cyst in between roots of teeth 33 and 34; (b) identification and enucleation of the cystic lining; (c) grafting the cyst cavity with xenograft bone and placement of a resorbable collagen membrane; and (d) reapproximation of the mucoperiosteal flap and closure with resorbable sutures.
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While the cystic lesion was identified and enucleated in total, mild adhesions to the lingual mucoperiosteum were released through blunt dissection using the surgical curette (Figure 2). The mucoperiosteal flap was reapproximated and closed with Vicryl 4-0 interrupted sutures (Polyglactin 910, ETHICON, Somerville, NJ, USA) (Figure 2).
Postoperative clinical photograph and radiographs at one-year follow-up showing (a) healthy gingiva and periodontium in between teeth 33 and 34; (b) periapical radiograph and (c) orthopantomograph showing no evidence of cyst recurrence and complete bone fill between roots of teeth 33 and 34.
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Moreover, teeth 33 and 34 were still vital during follow-up (Figure 3).
Histopathological examination of (a) the excised cystic lesion showing and (b) cystic lesion composed of reduced enamel epithelium-like lining comprising single or double layer(s) of flattened squamous or cuboidal cells and subtly thickened areas with more closely packed cells (arrow). The cyst wall is uninflamed throughout but demonstrates varying degrees of collagenization and cellularity. Cells with a clear cytoplasm are scattered throughout the lining (a). (c) A fragmented part of the lining showing a thickened cellular plaque with evidence of whorled (swirling) arrangement (blue arrow). Cells with a clear cytoplasm are also seen scattered in this plaque. (d) Another fragmented thickened epithelial plaque with areas showing ductal orientation (red arrow). Scale bars: 100 mum (a, c) and 200 mum (b, d).
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Considering the low risk of recurrence associated with the lesion, it was decided to follow up the patient closely (Figure 4).