Introduction
Non-keratinized, non-inflammatory developing cysts that are next to or lateral to the roots of important teeth are referred to as lateral periodontal cysts (LPCs). 1 Although it was referred to be a periodontal cyst, Standish and Shafer reported the first instance of LPCs in 1958, followed by Holder and Kunkel in the same year. 2, 3 The prevalence of LPC in developmental odontogenic cysts is very low. There is no sex preference for the location of lateral periodontal cysts (LPCs), which are most frequently found in the canine-premolar region of the mandible and less frequently in the maxilla (88 percent mandible and 12 percent maxilla). 4, 5 Additionally, abnormal LPC cases have been discovered in connection with unerupted teeth. 6 LPCs are found to occur less frequently than 1% of the time, and they account for just 0.8% of central maxillary bone cysts. 2 It is one of the developmental odontogenic cysts with a lower incidence. It mostly affects persons in their fifth to seventh decades of life and is uncommon in young people under 30. 7 LPC lesion is thought to form from the enamel epithelium, remaining Malassez, and dental lamina. 8
A well-circumscribed spherical or oval radiolucent region, usually with a sclerotic edge, can be seen on radiographs of the lateral periodontal cyst. Most of them are visible on the lateral surface of tooth roots and are smaller than 1 cm in diameter. 9 There are two types of LPCs: unicystic and multicystic. Due to similarities between the macroscopic and microscopic characteristics of the multicystic version of LPC and "bunch of grapes," it is known as Botryoid Odontogenic Cyst (BOC).4, 10 In the literature, reports of LPC occurring bilaterally in the jaws have also been explicated.11 When determining the differential diagnosis of a lateral periodontal cyst, it is important to take into account the possibility of radicular cysts, glandular odontogenic cysts, and odontogenic keratocyst tumor’s in the same area. 7, 12, 13
According to histopathology, LPCs are categorized as developing cysts with lumen linings that resemble decreased enamel epithelium and are lined by a thin, nonkeratinized epithelium that is typically one to five cell layers thick. 14 If left untreated, all odontogenic cysts may occasionally result in discomfort, root resorption, tooth displacement, and the growth of alveolar bone.15 The preferred course of treatment is surgical enucleation, which is followed by regular follow-up and radiographic monitoring to check for recurrences, even though they are rare. 16 The treatment of intraosseous cystic cavities has utilized a variety of regenerative techniques, including guided tissue regeneration (GTR) methodology employing various allografts and platelet rich plasma (PRP) technology. 17
The right mandibular lateral and canine region of a fourteen-year-old girl was the site of an interradicular radiolucent cystic lesion, which we present here as a case report.
Case Report
A 14-year-old female patient complained of right mandibular canine gum swelling for the previous four months to the outpatient oral medicine and radiology department. Although the history showed the presence of a swelling that began four months ago and steadily grew in size to the current day, there was also a history of sporadic mild to moderate pain experienced while chewing meals. The swelling was also associated with mobility in the mandibular anterior teeth. The patient had no overarching comorbidities and was in generally good health. Her previous dental history revealed that she had previously visited the dentist for the same concern regarding intraoral swelling. She was then advised to get an intraoral periapical radiograph of the right anterior mandibular region and was subsequently sent to the dental hospital for advice and consultation.
Figure 3
Intra oralperiapical radiograph showing an oval shaped big radiolucency between the roots of teeth 42 & 43
Figure 4
Orthopantomograph showing a well-defined big tear drop shaped radiolucency lateral to the roots of 42 & 43 with displaced roots
Figure 5
Hematoxylin & Eosin stained slide showing cystic cavity with 2-3 layered non-keratinized stratified squamous epithelium withy few epithelium plaques (low power veiw).
Extra oral examination showed unilateral diffused fluctuant swelling in the right side of lower lip region with normal overlying skin.(Figure 1) Intra oral examination revealed a single diffused gingival enlargement measuring about 20x15mm, seen in the 42, 43 region, involving the labial and lingual gingiva as well as the labial vestibule.(Figure 2) With grade II movable 41, 42, and 43 as well as distance between the lateral incisor and canine, the swelling was somewhat painful to palpation. All mandibular anteriors were found to be healthy during electric pulp testing.
An Intra-oral periapical (IOPA) radiograph of the site revealed an oval shaped big radiolucency between the roots of teeth 42 and 43(Figure 3). Orthopantomograph showed a tear drop shaped big well defined radiolucency measuring approximately 24x16mm in its largest dimension between the roots of 42 and 43 regions with displaced roots of the same (Figure 4). Tentative diagnosis of LPC was made based on the clinical and radiographic symptoms, with odontogenic keratocyst and glandular cyst included in the differential diagnosis.
The patient was then referred for additional evaluation and care to the Pedodontics and Oral Surgery departments. Under local anesthesia, a full-thickness mucoperiosteal flap was raised. The lesion was entirely excised, the cyst capsule was separated from the adjacent bone, and the specimen was subsequently sent for pathological investigation. The examination revealed a thin, non-keratinized stratified squamous epithelium resembling reduced enamel epithelium with few epithelial plaques seen (Figure 5). Further, concluding diagnosis of LPC was made. Analgesics and postoperative antibiotics were prescribed. Follow-up exams turned up no clinical or radiographic signs of the lesion recurring.
Discussion
LPCs are sometimes mistaken for other inflammatory and developing jaw cysts or tumors. It's much disputed where LPC came from. According to one study, they were present in 0.7 percent of the 2,616 cysts observed over an 11-year period. 8, 18 R Ramesh estimates that this odontogenic lesion only makes about 0.4% of all odontogenic cysts. 19
Since there is no evidence that LPC originated from a particular source, any theory concerning its genesis must be supported by presumptive evidence. 20 According to the available evidence, the lesion in the present case was present between the buccal root surfaces of the mandibular canine and lateral incisor, and the associated teeth were mobile and vital. The lateral periodontal cyst (LPC) can arise at periapical sites in two unusual cases, according to Nikitakis N. G. et al. They also came to the conclusion that LPCs are not necessarily site-specific and should be considered when making a differential diagnosis of radiolucent periapical lesions. 21 While Buchholzer et al. described a case of an LPC that emerged in the Pericoronal region of an unerupted mandibular canine. 6
According to their epithelial lining, odontogenic cysts are categorized as inflammatory & developmental by the World Health Organization. LPCs, or lateral periodontal cysts, have been thought of as a separate entity. 4 The disease is thought to have its origin in the enamel epithelium, Malassez remnants, and dental lamina. 8 Another explanation about the pathophysiology of lateral periodontal cysts proposes that a supernumerary tooth germ may have originated as a primordial cyst. 22 Meanwhile pain or other clinical symptoms have occasionally been reported and this cyst can be witnessed in routine radiological inspections. On occasion, a swelling on the labial surface of the gingiva may be observed, and it could be mistaken for a periapical or periodontal abscess.1, 19 A variability of pigmented type of LPC was reported by Chandel et al in 2019. 20
Most commonly in the fifth and sixth decades of life, adults between the ages of 40 and 70 are diagnosed with LPC. It is believed to have an equal impact on both sexes, while some studies have found a tiny 1.3:1 male predominance, 6 which was exactly at variance in our case wherein the cyst was appreciated in a young female patient aged 14 years which was found to be a rare report.
When a vital erupted tooth has a circular, well-circumscribed radiolucency on its lateral surface, especially in the mandibular premolar region and with a sluggish development rate that is predicted to be 0.7 mm/y, LPC is suspected.16, 21 In the present case, there was a big radiolucency appreciated laterally between the roots irt 42 and 43 region which again makes it unusual. These lesions can be diagnosed using diverse imaging techniques like Ultrasonography (USG). Surgery was used to treat LPC cases that had been identified by intraoral ultrasound (USG), cone beam CT, and conventional imaging. 19, 23, 24
According to histology, LPCs are lined by a non-keratinized squamous epithelium with epithelial plaques made of transparent fusiform cells and consisting of 1 to 5 layers of cells with a palisade distribution. 16, 18
Conclusion
The Lateral Periodontal Cyst is an uncommon developmental odontogenic cyst that meets the necessary histopathologic criteria and needs to be surgically removed as soon as possible. In the incisor to canine region of the jaw, a vast variety of cysts and anatomical structures are present, with LPC being a comparatively uncommon option. It can occasionally manifest in an atypical clinico-radiographic manner, in which case a thorough histological evaluation should be carried out.
