Recovery of Pulp Sensibility After The Surgical Management of A Large Radicular Cyst
Recovery of Pulp Sensibility After The Surgical Management of A Large Radicular Cyst
Recovery of Pulp Sensibility After The Surgical Management of A Large Radicular Cyst
ABSTRACT
In addition to pathogenic teeth associated with cysts, the roots of adjacent teeth are often included in the
cystic cavity. Whether these teeth require elective endodontic treatment followed by cystic enucleation re-
mains unclear. In the case presented herein, we aimed to preserve the pulp of the teeth included in the cystic
lesion. Unfortunately, the sensibility of the included teeth was negative after endodontic surgery, including
cystic enucleation. However, the sensibility recovered after 1 year and was maintained throughout a 4.5-year
follow-up. Therefore, we suggest that elective endodontic treatment of the included teeth should be avoided,
and further research should be conducted regarding this issue.
Keywords: Cyst, elective, endodontic, pulp, sensibility, surgery
HIGHLIGHTS
• There are currently no treatment guidelines for the teeth included in a cystic lesion.
• A lack of response to pulp sensibility testing should not be considered a conclusive indica-
Please cite this article as: Kim HJ, tor of pulp necrosis in included teeth.
Min KS. Recovery of Pulp Sensibility • Instruction-adherent patients are eligible for the preservation of pulp without elective en-
After the Surgical Management
of a Large Radicular Cyst: A Case
dodontic treatment.
Report with a 4.5-Year Follow-up.
Eur Endod J 2023; 8: 96-100
Address for correspondence: INTRODUCTION aspiration through the root canal, marsupialisa-
Kyung-San Min Bacterial contamination of pulp tissue results tion, apical resection, and surgical enucleation
Department of Conservative in the development of periapical lesions, such (6, 7). Among these treatments, surgical enucle-
Dentistry, School of Dentistry and
as periapical granulomas, periapical abscesses, ation of radicular cysts has been the most effec-
Institute of Oral Bioscience,
Jeonbuk National University, or radicular cysts. Radicular cysts, a subtype of tive and reliable method to treat the cysts (8).
Jeonju, Korea inflammatory cysts, are among the most com-
E-mail: endomin@gmail.com mon odontogenic cysts (1). Following pulpal In addition to the pathogenic tooth, adjacent
necrosis or insufficient root canal treatment, teeth are often located in the cystic capsule;
Received May 15, 2022,
Revised October 29, 2022, the inflammatory process may cause a large these healthy vital neighbouring teeth are re-
Accepted December 12, 2022 periapical lesion, such as a radicular cyst (2, 3). ferred to as “included teeth” or “involved teeth”
According to previous reports, the prevalence (9). When performing cyst enucleation, clini-
Published online: January 18, 2023 cians have long considered devitalisation of
of radicular cysts within periapical lesions varies
DOI 10.14744/eej.2022.30085
between 15-55% (4, 5). The current literature the included teeth to be inevitable (10). There-
This work is licensed under proposes different therapies to treat radicular fore, the rationale for prophylactic treatment is
a Creative Commons
Attribution-NonCommercial
cysts, such as conservative root canal treatment to prevent future apical periodontitis. Notably,
4.0 International License. without adjunctive therapy, decompression, elective (so-called intentional) endodontic
EUR Endod J 2023; 8: 96-100 Kim and Min. Recovery of Vitality After Surgery 97
CASE PRESENTATION
a b a b
c d
c d
After 6 months, an electric pulp test and cold test were per- tributed to several mechanisms. First, we verified blood filling
formed on the included teeth (#31, 32, and 41), and the re- in the bony cavity before flap repositioning, which might have
sults were positive on #31 and 32 but not on #41. Finally, the affected recovery. A previous review claimed that blood clots
pulp of #41 was found to be sensible on a 1-year follow-up formed in the bone cavity after cyst enucleation could poten-
visit (Fig. 3a). Therefore, the pulp sensibility of all the included tially promote revascularisation (17). The authors stated that
teeth recovered. Furthermore, root resorption limited to the the blood clot seems to be a natural biological filling of the
apex of the teeth was also observed (Fig. 3b). At a 4.5-year fol- residual cavities, when it is able to conserve the residual bone
low-up, complete bony healing was found, and all included walls provided by the periosteum and endosteum (18). In ad-
teeth showed no problems regarding function and tooth dis- dition to the role of the blood clot as a natural cavity filling, it
colouration. All included teeth (#31, 32, and 41) responded also contributes to nerve regeneration. First, the blood clot is
normally to sensibility tests, including the electric pulp and a rich source of various growth factors involved in neurogen-
cold tests. Pulp sensibility was maintained (Fig. 3c), and root esis and angiogenesis (18). Secondly, one of the hypothesised
resorption did not progress (Fig. 3d). mechanisms attributes reinnervation to the survival of dental
pulp stem cells (DPSCs) from residual vital apical pulp tissue.
DISCUSSION Even in mature teeth, some vital pulp tissue might remain de-
Many clinicians choose to devitalise included teeth because spite the presence of a periradicular lesion (19). In addition,
of the risk of possible trauma or inflammatory reaction when DPSCs have the potential to differentiate into neuronal cells
performing the enucleation of radicular cysts (14, 15). More- in vitro and can induce axon guidance (20). Thirdly, another
over, a negative response to sensibility tests before or after possible mechanism is that the pulp canal receives collateral
cyst enucleation surgery generally indicates pulp necrosis reinnervation by the sprouting or ingrowth of neighbouring
(16). However, efforts should be made to avoid unnecessary ipsilateral nerves, similar to reinnervation in reimplanted or
devitalisation whenever possible because of the pivotal role of autotransplanted teeth after surgery or involved teeth after
vital pulp in defence and repair mechanisms and their inher- mandibular fractures (21, 22).
ent value as a source of stem cells. In this case, the pulp sensi-
bility of the included teeth recovered even though the vessels The situation in the present case is similar to that of autotrans-
and nerves were presumably completely amputated during planted teeth in terms of vessel and nerve amputation. Tradi-
the cyst enucleation procedure. Nevertheless, nerve regenera- tionally, the pulp of mature teeth is not expected to survive
tion is thought to have occurred, and this recovery may be at- after autotransplantation. However, in some cases, revascular-
EUR Endod J 2023; 8: 96-100 Kim and Min. Recovery of Vitality After Surgery 99
isation has been observed after autotransplantation (23, 24). is seen as a narrow radiolucency between the root and lamina
Presumably, the likelihood of pulpal infection or damage to dura (Fig. 3d). In addition, tooth #41 showed partial pulp oblit-
the included teeth in cystic lesions may be lower than that in eration with no apparent crown discolouration. Presumably,
replanted teeth. In addition, all the included teeth, in this case, the included teeth inevitably underwent trauma during sur-
were single-rooted, and the wide apical foramina might have gical enucleation of the cyst. Calcific metamorphosis consists
facilitated revascularisation. Indeed, in extracted transplants, of the pulp response to trauma, characterised by the rapid de-
adverse findings were found more frequently in molars than position of hard tissue within the root canal and pulp chamber
in premolars or canines (24). space. However, the exact pathophysiological mechanism un-
derlying pulp canal obliteration remains unknown.
In this case, we did not perform any regenerative approach us-
ing a bone graft or membrane after cyst enucleation, although CONCLUSION
these are frequently used in various surgical procedures. Ac- Attempting to preserve the pulp sensibility of the included
cording to the review article by Lin et al. (25), biologically, a teeth is worthwhile because doing so preserves the physiolog-
blood clot is a better space filler than bone grafting materials ical and anatomical functions of the teeth. However, the results
since it contains the own biologic products of the host to pro- from the sensibility test on the included teeth should be inter-
vide an excellent scaffold. They also concluded that no defini- preted with caution. Instruction-adherent patients are eligible
tive evidence demonstrates that the application of membrane for this option because strict periodic follow-up is required to
barriers in large bony lesions has a better long-term outcome monitor the status of the teeth to prevent complications.
than a control group in periapical surgery (25). Meanwhile, a key
factor for bony repair is the periosteum because it may act both Disclosures
as a source of osteocompetent cells and as a barrier against the Informed consent: Written informed consent was obtained from the patient
infiltration of epithelial cells into the healing site (26). Similarly, for the publication of the case report and the accompanying images.
according to a more recent literature review of cyst enucleation, Conflict of interest: The authors deny any conflict of interest.
the available data did not indicate the superiority of additional
Peer-review: Externally peer-reviewed.
bone grafts (4). Furthermore, a radiopaque bone filler or bone
substitute may confound the radiographic interpretation of pe- Financial Disclosure: This research was supported by a grant from the Korea
riapical healing. Even though the usefulness of bone grafts for Medical Device Development Fund grant funded by the Korean government
revascularisation of the included teeth remains incompletely (the Ministry of Science and ICT, the Ministry of Trade, Industry and Energy, the
investigated, the present case supports the opinion that careful Ministry of Health & Welfare, Republic of Korea, the Ministry of Food and Drug
enucleation of a large radicular cyst without bone grafting may Safety) (Project Number: RS-2020-KD000045).
be performed without complications. Authorship contributions: Concept – K.S.M.; Design – K.S.M.; Supervision –
K.S.M.; Funding - K.S.M.; Materials - K.S.M.; Data collection and/or processing –
The lesion size and type should be considered when deciding K.S.M.; Analysis and/or interpretation – H.J.K.; Literature search – H.J.K.; Writing
whether to use a regenerative approach using a membrane – H.J.K.; Critical Review – K.S.M.
barrier in endodontic surgery. The best application of mem-
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