There are some cases that really stick with you… and this was one of them! There are radicular cysts and then there are radicular CYSTS. This radicular cyst was one big mofo, and it needed to be enucleated. I teamed up with a periodontist to take care of this patient.

WARNING: This case has GRAPHIC CONTENT. (No, seriously.) 

This tooth story started off with a lesion on a radiograph that was just enormous… and then it looked even bigger on the CBCT. (Of course, it helps that my CBCT is my best friend and lets me see so much.)

I’m curious to know how you would’ve managed this case, because it was a DOOZY. Would you have treated it the same way I did, or would you have taken a different approach? Please leave a comment to let me know!

A Big Lesion on the Radiograph Was Just the Beginning…

The patient presented to my practice with very little pain, but he had a bump under his palatal tissue that would occasionally swell up. Although this had been going on for several years, he wasn’t very concerned about it since it never really got too bad and didn’t really hurt. 

The area wasn’t swollen and there wasn’t a sinus tract—rather, it felt like a firm, 1cm ball was planted under his tissue. I would discover that it was a radicular cyst, which you do see in endodontics from time to time. 

None of his teeth in that area responded to the cold test, and there was no pain to percussion. 

Here is his periapical radiograph.

lesion on the radiograph-1

Well hello there, giant lesion! It was too big to see in its entirety on the radiograph, so I knew I needed a CBCT. This is what the imaging showed:

lesion on the radiograph - 3

Holy lesion, Batman! I mean, this thing was truly off the charts! I am STILL dumbfounded at the lack of pain this patient was evidently experiencing.

Having seen how large the lesion was on the radiograph and then completing further examination with my CBCT, it was clear: This would not heal from a root canal alone. This patient needed root canal therapy and surgery. 

And since this was a bit more extensive than what I like to do on my own, I teamed up with my periodontist, who rocks at this. (We’ve done so many of these treatments together that he refers to them as the “Chopra Special.”)

Endodontic Diagnosis and Surgery

I was able to diagnose the patient with Necrotic Pulps #9, #10, and #11, and Asymptomatic Apical Periodontitis #9, #10, and #11 (some may argue that this may be an Acute Apical Abscess).

Actually, I wasn’t convinced that tooth #11 was necrotic (even though it didn’t respond to cold), but I knew that, after surgery, that tooth would likely get devitalized, so I included it in the treatment plan.

lesion on the radiograph - 4

That radicular cyst had done some serious damage. Are you ready to see what this looked like, surgically? WARNING—GRAPHIC CONTENT.






Alright, you asked for it. Take a look: The buccal plate was completely gone.

lesion on the radiograph - buccal plate gone

 And so was the lingual plate…

lesion on the radiograph - lingual

You could actually fit the entire periosteal elevator from the buccal to the lingual side…

lesion on the radiograph

Here is a close-up of the palatal bone….

 lesion on the radiograph - closeup

A bone graft was placed…..

 lesion on the radiograph - bone graft

And since it was a through-and-through lesion, a membrane was placed, too…

 lesion on the radiograph - membrane placed

This is what he looked like in the immediate post op:

 lesion on the radiograph - post-op

lesion on the radiograph - post-op 2

And a few weeks later…

 lesion on the radiograph - healing

lesion on the radiograph - healed

Once the tissue had a chance to heal from that whopper of a radicular cyst, I completed the root canals and restored the access of each tooth with a composite restoration. 

Can you believe it after seeing that huge lesion on the radiograph and then the images of what was really going on? Incredible.

I’ll never stop being amazed at how beautifully restorative endodontic procedures are and how resilient our teeth can be.

lesion on the radiograph - all gone

A Waiting Game

Next, it was a waiting game to see that bone fill back in. But don’t get fooled by this postoperative radiograph—that’s just the bone graft that makes it look totally healed! There was still plenty of time to go before everything was totally back to optimal health in this case.

This patient was aware that this lesion could take several years to completely heal, so I asked him to be prepared to wait. 

Keep that in mind when you’re treating cases like these, and prepare your patients for what to expect. Massive lesions and bone loss really can take up to 4 years to exhibit complete healing. That’s just the nature of the game when you’re dealing with a seriously big radicular cyst that’s left untreated for so long.

Here are his one-year recall images. I am so happy that he healed up so nicely. What a doozy of a tooth story!

Radicular Cyst

Radicular Cyst

So… now you’re up to bat.

If this had been your patient, what would you have done? Would you have taken these teeth out? Would you have treated them the same way I did? Something else?

My way is NOT the only way! For instance, you might have done an apicoectomy, which is totally valid. I opted not to, since these teeth weren’t previously treated, endodontically.

Leave a comment and let me know your thoughts.

This is a doozy of a case, so if you want to test your knowledge, I invite you to take my Endodontic Know-How Quiz! It will help you gauge just how confident you are about endo, as well as your potential areas for growth.


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