Tichvy Tammama, Fistula Management Due To Chronic Infection Of Radicular Cyst:. Vol. 01 No.

02:
Journal of Health and Dental Sciences.e-ISSN 2807-3126 209-218

FISTULA MANAGEMENT DUE TO CHRONIC

INFECTION OF RADICULAR CYST
(PENATALAKSANAAN FISTULA AKIBAT INFEKSI
KRONIS PADA KISTA RADIKULAR)
Tichvy Tammama1*, Winda Afrilia Megayanti1
1
Department of Oral Surgery and Maxillofacial Faculty of Dentistry,
Universitas Jenderal Achmad Yani Cimahi Indonesia
*Corresponding author
[email protected]
JHDS.unjani.ac.id/jite
Doi:10.xxxx/jite
ABSTRACT
Article History
Received:15/09/2021 A radicular cyst is the most common odontogenic cyst that arises from
Accepted: 30/09/2021
the epithelial residues in the periodontal ligament due to periapical
periodontitis following death and necrosis of the pulp. A fistula may
form a cyst with a pulp infection that produces pus and seeks its way out
to the gingival surface to create a canal. The purpose of this case report
is to report the management of a patient with a chronically infected
radicular cyst with fistula while retaining the involved tooth. A case
report was a 13-year-old female patient who came to Department Oral
Surgery of a hospital with a complaint of a lump in the front gum and
palate that didn't heal for two years ago and often discharged pus.
Intraoral examination showed a lump in the gingiva and palate with
fistula in the interdental gingiva of teeth 11-12 with soft consistency and
pain with palpation. Panoramic results showed characteristics of the
radicular cyst at the 13-11 tooth region. The lesion is diagnosed as a
chronic infection of a radicular cyst due to pulp necrosis in teeth 12-11
with interdental fistulas. Biopsy enucleation of the cyst was performed
with teeth preservation. The patient was advised to have regular check-
ups. On the sixth month of control, the surgical wound was good,
without any complaints and signs of recurrence. The result is that a
radicular cyst can become chronically infected and form a fistula that
oozes pus into the oral cavity. The cyst can be treated with enucleation
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 biopsy and fistulectomy with the preservation, without any recurrences.
Keywords: cyst; enucleation; fistula; infection; radicular

ABSTRAK
Kista radikular merupakan kista odontogenik yang paling sering timbul
dari sisa epitel ligamen periodontal akibat periodontitis apikalis pada
gigi yang nekrosis. Fistula dapat terbentuk pada kista apabila gigi
tersebut mengalami infeksi dan menghasilkan pus yang mencari jalan
keluar melalui gingiva sehingga terbentuk saluran. Tujuan laporan
kasus ini untuk menjelaskan penatalaksanaan pasien dengan kista
radikular yang mengalami infeksi kronis disertai fistula dengan tetap
mempertahankan gigi yang terlibat. Laporan Kasus: Pasien anak
perempuan berusia 13 tahun datang ke bagian Bedah Mulut di sebuah
Rumah Sakit dengan keluhan terdapat benjolan di gusi depan dan
palatum yang tidak sembuh sejak 2 tahun yang lalu serta sering
mengeluarkan nanah. Pada pemeriksaan intraoral tampak benjolan
pada gingiva dan palatum disertai fistula pada gingiva interdental regio
gigi 11-12 dengan konsistensi lunak dan nyeri saat ditekan.
Pemeriksaan panoramik memperlihatkan gambaran kista radikular
pada regio gigi 13-11. Lesi didiagnosis sebagai kista radikular
terinfeksi kronis akibat nekrosis pulpa gigi 12, 11 disertai fistula pada
interdental 12-11. Dilakukan biopsi enukleasi kista dengan tetap
mempertahankan gigi yang terlibat. Pasien disarankan untuk kontrol
berkala. Pada kontrol 6 bulan, luka tampak baik, tanpa keluhan dan
tanda-tanda rekurensi. Kista radikular dapat mengalami infeksi kronis
hingga terbentuk fistula yang mengeluarkan pus ke rongga mulut.
Umumnya kista dapat ditangani dengan biopsi enukleasi dengan tetap
mempertahankan gigi yang terlibat, tanpa rekurensi.
Kata kunci: enukleasi; fistula; kista radikular; infeksi;

INTRODUCTION membranous tissue filled with fluid or semi-

A cyst is a pathologically sac-like pocket of fluid that develops abnormally in space or

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organs.1 Radicular cyst is the most common phase 3, the developmental stage of the cyst
in odontogenic cysts. In one of the jaws until it reaches a large size.4 Surgical
cyscomesome from the remnants, epithelial procedures for the management of radicular
Malassez of the periodontal ligament due to cysts may include extraction, enucleation,
chronic inflammation or irritation from root and marsupialization, and non-surgical
canal infect. It begins with periapical procedures in some cases may include root
granuloma formation as a result of bacterial canal treatment.5,6,7
infection and pulp necrosis.1,2 Radicular In this case report, the authors describe
cysts have the highest frequency in the third a case in a 13-year-old female patient with
decade of life, and there are many cases a diagnosis of an infected radicular cyst due
involving the fourth and fifth decades of to pulp necrosis of teeth 12, 11 with
life. This case is more common in men than interdental fistulas 12-11 with extirpation
women, with maxillary 60% and biopsy and fistulectomy under general
mandibular 40%. Most of these cases occur narcotics. It is followed by antibiotic
in the maxillary anterior region, which is medication and anti-inflammatory and
more vulnerable to traumatic injury and periodic control in a week.
caries, where the incisors and canines are
generally the most common locations.3,4 CASE REPORT
Radicular cysts are found chiefly A 13-year-old female patient came to
incidentally when radiographs are Oral and Maxillofacial Surgery Clinic of
performed for nonvital teeth. Radicular AMC Hospital, Bandung, with her mother
cysts are asymptomatic, and patients complaining of a lump in the front gum that
usually complain of swelling that gets didn't heal since two years ago and was
bigger over time and disturbing often discharged pus. The patient also
aesthetically and functionally, involves complains of frequent swelling of the palate
mobility and migration of other teeth.1,4 The that comes and goes. The results of the
radiography appearance is round or oval intraoral examination showed fistulas in the
with radiolucent content surrounded by a interdental region of teeth 11-12 (Figure 1)
radiopaque border that extends the lamina and swelling in the palatal areas of 13-11
dura of the involved tooth.4 The with a soft consistency and pain when it got
pathogenesis of the cyst consists of three pressed (Figure 2). On aspiration
phases, namely phase 1, the initiation phase, examination, there was a small amount of
phase 2, which the cyst begins to form, and clear fluid mixed with pus.

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 with a size of 2x1 cm with firm boundaries
and resembling a cyst (Figure 3). Based on
the examination results, a clinical diagnosis
is a chronic infection of a radicular cyst due
to pulp necrosis of teeth 12, 11 with
interdental fistula.

Figure 1. Intraoral examination showed a

lump in the gum of the 11-12 tooth region
with fistula.

Figure 3. Panoramic results showed

characteristics of the radicular cyst at 13-
11 tooth region.

The treatment performed on the

patient was extirpatory biopsy and
fistulectomy under general narcotics. The
position of the patient is in a lying place
Figure 2. Intraoral examination showed when the operator will carry out the
swelling in the palatal of 11-13 tooth treatment. The treatment consists of several
region. stages: extraoral and intraoral aseptic and
antiseptic using povidone iodine, insertion
The patient underwent a panoramic of an oropharynx pack, and infiltration
radiological examination that shows anesthesia on the labial and palatal with a
radiolucent on the mesial and distal of the syringe containing pehacaine. After the
crown 11-12 tooth from the enamel to the anesthetic condition was achieved, the
pulp. It was a radiopaque image resembling lesion was aspirated, and one cc of pus was
restorative material in the mesial and obtained. The operator did a triangular flap
radiolucent on the distal of the crown of 13 on the gingiva 11-13, then dissected and
teeth from the enamel to the pulp. There is found a cyst wall and fistula on the labial
a round radiolucent appearance on the side with size 0,7x0,7x0,5 cm with pus
periapical of the 11-13 roots of the tooth coming out. An exploration and excision of

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the fistula are performed on the labial side to further examination at Pathology
(Figure 4). Anatomy (Figure 7).

Figure 4. Post fistulectomy, fistula with

bone base appear.
Next, do a flap envelope on the
Figure 6. Wound cleaning and insertion of
palate of the 14-21 tooth region, dissect and
gauze into the hole.
find a cyst capsule wall with size 2x1,5x1,5
cm filled with pus, then explore and remove
the cyst wall are performed (Figure 5).

Figure 7. Specimen of cyst capsule with

fistula.
On the fourth day of control, there was
Figure 5. Post enucleation of the cyst on a
no complaint from the patient, the surgical
palatal view.
wound was good, and the gauze was
After completion, control bleeding and
removed. On the seventh day of power, the
debridement in the post-enucleated area
patient histopathological examination result
with betadine and 0,9% NaCl. Insert a rolled
concluded an infected radicular cyst. There
gauze that has been given chloramphenicol
was no complaint; the surgical wound was
into the post enucleation hole and suture the
good, then stitches could be opened. The
wound (Figure 6); the procedure is
patient came back for control in the sixth
complete. The specimen in the form of a
month without any complaints and signs of
cyst wall that had been taken was subjected
recurrence.
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 mandible, it is usually labial or buccal and
DISCUSSION
rarely lingual.8
A radicular cyst is the most common cyst in
Radicular cysts most likely result
odontogenic cysts. It arises from the
from bacterial infection of pulp necrosis,
epithelial residues in the periodontal
bacteria that initiate inflammation in the
ligament due to periapical periodontitis
pulp and periapical tissues produce
following death and necrosis of the pulp.
chemical mediators that cause periapical
Cysts arising in this way are found most
soft tissue proliferation and stimulate
commonly at the apices of the involved
osteoclastic activity, inflammatory cell
teeth but may also be found on the lateral
cytokines, and growth factors released
aspects of the roots concerning lateral
during apical periodontitis that can
accessory root canals.8
stimulate residual epithelial cells Malassez
Many radicular cysts are symptomless
in the apical periodontal ligament to
and are discovered when radiographs are
develop and form cysts.9,10
taken of teeth with nonvital pulps.8 The case
Pain and infection are other clinical
of radicular cyst reported this time
features of some radicular cysts. It is often
happened to a 13-year-old female patient
said that radicular cysts are painless unless
with a complaint of a lump in the front gum
infected. However, there seems to be no
and the palate for two years ago and often
clear correlation between infection and
discharge pus. The clinical picture showed
symptoms. Some patients complain of pain,
fistula in the interdental region of 11-12 and
although no evidence of infection is found
swelling in the palatal area 13-11 with
clinically, and no evidence of acute
tender consistency and pain when pressed.
inflammation is seen histologically after the
Radicular cysts are the most
cyst has been removed. Likewise, some
common cause of swelling of the jaws, and
patients have clinically infected and
slowly enlarging swellings complain. At
histologically inflamed cysts which are not
first, the enlargement is bony hard, but as
painful.8
the cyst increases in size, the covering bone
Occasionally, a fistula may lead
becomes very thin despite subperiosteal
from the cyst cavity to the oral mucosa.8 A
bone deposition, and the swelling then
fistula is an abnormal canal between two
exhibits springiness. Only when the cyst has
organs with the outer surface as drainage
completely eroded the bone will the lesion
because the periapical pus seeks its way out
be fluctuant. There may be buccal or palatal
to the gingival surface. The fistula is lined
enlargement in the maxilla, whereas, in the

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with granulation tissue and inflammatory along these channels and into the cyst cavity
cells and may resolve once the infection of through interepithelial spaces on the
the pulp and necrotic tissue in the root canal luminal surface. As the cyst enlarges, the
has resolved.11 wall may become less inflamed and fibrous.
On aspiration examination of the It is the most noticeable distance from the
patient, there was a small amount of clear apex of the tooth.8
fluid mixed with pus. The contents of cyst The patient radiographic appearance
cavities were subject to an osmotic showed a radiolucent image on the mesial
imbalance with the surrounding tissues and distal of the 11, 12 tooth crown from the
because of the absence of lymphatic enamel to the pulp. There is a radiopaque
drainage. Lytic products of the epithelial image resembling a restorative material in
and inflammatory cells in the cyst cavity the mesial and radiolucent on the distal of
provided more significant numbers of the 11-13 tooth from the enamel to the pulp
smaller molecules, which raised the osmotic and a round radiolucent image on the
pressure of the cyst fluid. Deposits of periapical of the 11-13 tooth roots with size
cholesterol crystal are found in many 2x1 cm with firm boundaries and
radicular cysts, but by no means in all. The resembling a cyst.
primary source of cholesterol was from The radiological appearance description of
disintegrating red blood cells in a form that radicular cysts is that they are round or
readily crystallizes in the tissues. ovoid. Radiolucency are surrounded by a
Cholesterol from this source and serum narrow radiopaque margin that extends
accumulates in the tissues because of the from the lamina dura of the involved tooth.
relative inaccessibility of normal lymphatic In infected cysts, the radiopaque margin
drainage.8 may not be present. There is no correlation
The inflammatory cell infiltrates in the between the loss of radiographic
proliferating epithelial linings consist certification and the increasing intensity of
predominantly of polymorphonuclear acute inflammation. Root resorption is not
leucocytes, whereas the adjacent fibrous often seen on routine radiographs, but it
capsule is infiltrated mainly by chronic may occur.8
inflammatory cells. The proliferation Treatment of radicular cysts can be
epithelial linings show a considerable done by root canal treatment, extraction,
degree of spongiosis. The enucleation, marsupialization.11 In this
polymorphonuclear leucocytes migrate case, the patient's cyst was treated by

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enucleation to extirpate the cyst. tract at the labial 13, 12 interdental
Enucleation is the primary choice in the gingivae.
treatment of most odontogenic cysts. It was irrigating and drying the
Enucleation is the process by which the total cavity with gauze aids in visualizing the
removal of a cystic lesion is achieved. It entire bony cavity. Residual tissue is
means a shelling-out of the entire cystic removed with curettes. The bony edges of
lesion without rupture. Enucleating cysts the defect should be smoothed with a file
should be performed to remove the cyst in before closure. A cyst surrounding tooth
one piece without fragmentation by roots or in inaccessible areas of the jaws
removing the whole cyst, including the requires aggressive curettage, which is
epithelium and the capsule, from the bone necessary to remove fragments of the cystic
wall without leaving any pathological wall.12
tissue.12 After enucleation, the wound should
The main advantage of enucleation be irrigated with sterile saline. An
is that pathologic examination of the entire appropriate length of strip gauze lightly
cyst can be undertaken. Enucleation treats impregnated with antibiotic ointment
the lesion so that once the mucoperiosteal should be gently packed into the cavity to
access flap has healed, the patient is no prevent dehiscence and infection. A
longer bothered by the cystic cavity.12 watertight primary closure should be
Once access to a cyst has been obtained with the sutures. In this case, we
achieved through an osseous window, the used polyglycolic acid 4-0 to safely
cyst begins to enucleate. A thin-bladed decompose the surgical string in the body
curette is used for cleaving the connective without leaving suture marks. The bony
tissue layer of the cystic wall from the bony cavity fills with a blood clot, which then
cavity. The curette then be used with the organizes over time. Granulation tissue is
concave surface should always keep facing seen on the bony walls in 3 to 4 days and
the bony cavity; the edge of the convex slowly obliterates the cavity and obviates
surface performs the stripping of the cyst, the need for packing. The oral epithelium
then the cyst separates form the bony cavity. then closes over the top of the opening, and
Once the cyst has been removed, the bony osseous healing progresses. Jaws that have
cavity should be inspected for remnants of been expanded by cysts slowly remodel
tissue.12 Fistulectomy was performed as a themselves to a more normal contour.12
treatment to completely excise the fistula Other medical therapy was given to

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patients, such as an antibiotic like Gauze that has been given chloramphenicol
ceftriaxone. It was to prevent postoperative is useful as antibiotic therapy in the wound
bacterial infections; ceftriaxone was chosen area to prevent disease after surgery.
because it has a large spectrum that works The opening of the sutures was carried
by inhibiting the synthesis of microbial cell out on the seventh day, where the wound
walls.13 healing process on the seventh day had an
Anti-inflammatory drugs were given to excellent reepithelialization process, and
patients, such as dexamethasone and the new epithelial tissue formed had
ketorolac. It was to prevent inflammation matured. A new layer of corneum was
and pain in the oral mucosa in the surgical usually clearly visible.
area. Dexamethasone was chosen as a
corticosteroid drug that can inhibit CONCLUSION
phospholipase A2. It causes prostaglandins In this case report, the patient had a chronic
and leukotrienes to form, disrupts infection of a radicular cyst due to pulp
inflammatory mediators, and reduces tissue necrosis of teeth 12, 11 with interdental
edema. Ketorolac was chosen as a non- fistulas 12, 11. Surgical management has
steroidal anti-inflammatory drug that could been done by extirpating biopsy. It was with
inhibit prostaglandin production, and a fistulectomy in general narcotics, and the
ketorolac is commonly used to treat healing was good without any
moderate to severe pain.14,15 complications.
Ranitidine can prevent irritation of the
CONFLICT OF INTEREST
stomach due to excess acid production.
We declare that there is no conflict of
Some pain relievers have side effects on the
interest in the scientific articles.
stomach in excess acid production or
irritation, so ranitidine was chosen as ACKNOWLEDGEMENT
Our gratitude goes to the Faculty of
protection against the abdomen.16
Dentistry, Unjani, and AMC Hospital
The patient took control on the fourth
professionals who have helped with this
day for the release of the gauze. On the third
case report and draft papers.
day, primary wound healing occurred. It
was a process of epithelialization and
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