Management of radicular cyst and fibrous epulis in an 11-years old girl

90
Vol. 59, No. 3, September-Desember 2010, Hal. 90-94 | ISSN 0024-9548

Management of radicular cyst and fibrous epulis
in an 11-years old girl

Helsa Ramelya1 and Heriandi Sutadi2
1
2

Residence of Department,
Lecturer of Department,
Pediatric Dentistry, Indonesia University

Correspondence: Helsa Ramelya, Departement of Pediatric Dentistry, Indonesia University. Email : helsa_ramelya@yahoo.com

ABSTRACT
Background: Radicular cyst is the most common lesion of the jaw. The fibrous epulis is applied to any lump arising from
gingival, resembles a fibroepithelial polyp, but also usually has an inflammatory component. Purpose: The aim of this study is
to management radicular cyst and fibrous epulis in order to restore the function of mastication and esthetic. Case: This case
report describes the management of radicular cyst and epulis fibromatosa in an 11-year old girl. Case management: The

treatment comprised extraction of the permanent teeth involved and excision of the fibrous epulis in region 36. Recurrence does
not occur after 6 month of the treatment since the tooth associated with the cyst has been removed, and the epulis was removed
thoroughly. Conclusion: Radicular cyst and fibrous epulis does not recur after adequate treatment.
Key words: Radicular cyst, extraction, excisional, fibrous epulis

INTRODUCTION
The radicular cysts are the most common cause
of major, chronic swellings and the most common
type of cyst of the jaws. They are more common in
males than females, roughly in the proportion of 3 to
2. The maxilla is affected more than three times as
frequent as the mandible.1,2 They are rarely seen
earlier than the age of 10 and are most frequent
between the ages of 20 and 60 years.1 Radicular cysts
are rare in the primary dentition, representing only
0·5–3·3% of the total number in both primary and
permanent dentitions.3-5
Various reasons cited for this relative rarity
include the presence of deciduous teeth for a short

time, easy drainage in deciduous teeth due to the
presence of numerous accessory canals and a
radicular radiolucency in relation to deciduous teeth
are usually neglected. Additionally, the lesions tend
to resolve on their own following the extraction/
exfoliation of the associated tooth and are generally
not submitted for histopathological examination. The
most commonly involved deciduous teeth are
mandibular molars (67%), maxillary molars (17%)
followed by anterior teeth.6
Radicular cysts are usually asymptomatic and
are left unnoticed, until detected by routine
radiography.3 Most radicular cysts develop slowly
and do not become very large. Caries is the most

Ramelya and Sutadi : Management of radicular cyst and fibrous epulis in an 11-years old girl
Jurnal PDGI 59 (3) Hal. 90-94 © 2010

frequent aetiological factor of radicular cysts in the
primary dentition.4 In the permanent dentitions the

high frequency of radicular cysts results from trauma,
caries and old silicate restorations.5
Radicular cyst is generally defined as arising from
epithelial residues (rests of Malassez) in the periodontal
ligament as a consequence of inflammation, usually
following the death of dental pulp.5-7 Typically, infection
spreads to the apex (root) of the tooth, leading to
secondary apical periodontitis, granuloma, or abscess
and, finally, cyst formation.8
Clinical presentation : a) asymptomatic unless there
is an acute exacerbation; b) usually a limited process at
root apex or lateral to root surface; c) radiograph shows
a round and well-defined radiolucency, usually with a
sclerotic margin; d) generally 1 cm or less across, but
can be significant in size, e) root resorption uncommon.9
The diagnosis was based upon documentation of
nonvital tooth and radiograph shows alteration of apical
bone. The differential diagnosis are: 1) periapical
granuloma; 2) central giant cell granuloma;
3) odontogenic and nonodontogenic tumors;

4) metastatic tumor. And microscopic findings are :
a) stratified squamous epithelial lining; b) lumen filled
with cell debris, fluid, cholesterol; c) connective tissue
wall with mixed inflammatory infiltrate.9
Treatment consists of enucleation of the cyst
lining coupled with root canal treatment and, in some
instances, retrograde surgical endodontic treatment
which consists of surgical exposure of the root apex
followed by amputation of the root apex and
obturation of the opening of the pulp canal, extraction
of the tooth and biopsy.9,10 Prognosis is excellent and
occasional recurrences.9 Radicular cyst do not recur
after adequate treatment.4
The term epulis is applied to any lump arising
from gingiva.11 Epulis are generally more common in
females than in males, with a prevalent age
distribution between the third and fifth decades of life
(mean age 37.1 years). Frequently, the lesions are
located arround anterior teeth, with significant esthetic
implications.12

Traumatic and inflammatory factors constitute
favourable conditions for epulises development. Their
size varies from 2.5 to 3 cm, and in most cases they are
pediculate, and the colour depends on the tissue
structure.13 The color ranges from lighter shades
similar to the surrounding tissues as a consequence of
an increased quantity of collagen and to red as a
consequence of the abundance vascularized
granulation tissue. Lesions are painless, as nerves do
not proliferate within the reactive hyperplastic tissue.12

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One of the most common epulis in children is
due to exuberant fibro-epithelial reaction to plaque.14
The etiologic factors of epulis are trauma, chronic
irritation (eg, subgingival plaque and calculus), and
bacterial infection.12 Irritation of the gingival margin
by the sharp edge of a carious cavity or by calculus
may lead to the formation of a fibrous epulis.2 Its

structure is dominated by mature connective tissue
and a network of collagen fibres with a small addition
of blood vessels.13
Clinical features, the variable inflammatory
changes account for the different clinical
presentations.from red, shiny and soft lumps to those
which are pale, stippled and firm. Commonly, lesions
are round, painless, pedunculated swellings arising
from the marginal or papillary gingiva, sometimes
adjacent to sites of irritation (e.g. a carious cavity);
they rarely involve the attached gingiva, and rarely
exceed 2 cm in diameter. The diagnosis is clinical but
most lesions need to be removed and examined
histologically.11
Accepted treatment of fibrous epulis includes the
excisional biopsy. Fibrous epulides should be
removed down to the periosteum, which should be
curetted thoroughly.11,12 An excisional biopsy is the
ideal approach for small lesion, where the clinical
appearance suggests that it is benign. Excision should

include a 1-2 mm margin of normal tissue
surrounding the specimen and allow for primary
closure (Figure 1).15 Removal of a large epulis from
the labial aspect of the maxillary gingival may create
an unsightly gingival defect, about which patients
should be warned in advance.16
There should be no recurrence if excision is done
thoroughly and the source of irritation is removed.
Histological examination is needed to confirm that an
epulis is fibrous and not a giant-cell lesion, pyogenic

Figure 1. Excisional biopsy.15

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Ramelya and Sutadi : Management of radicular cyst and fibrous epulis in an 11-years old girl
Jurnal PDGI 59 (3) Hal. 90-94 © 2010

granuloma or a malignant tumour.2 Histologically, it
comprises chronically inflamed, hyperplastic fibrous

tissue, which may be richly cellular or densely
collagenous.17
The aim of this study is to management of
radicular cyst and fibrous epulis in order to restore
the function of mastication and esthetic.

36 involving 1/3 middle of the root until apex mesial,
approximately 1 cm in diameter (Figure 3). Based on
the history, examination and clinical findings
a provisional diagnosis of a radicular cyst and fibrous
epulis was made.

CASE MANAGEMENT
CASE
An 11 year-old girl came to the Department of
Pediatric Dentistry, Indonesia University, with the major
complain of having a painless swelling on her lower
left posterior region of the mouth causing her difficulties
in chewing. Her mother reported that this painless
swelling had been there for the past 1 month and the

size is small, but somehow now has become larger.
Intra oral examination, a well-defined spherical
swelling of approximately 1 cm in diameter was noticed
in the left lower gingival region 36, red in color, soft
consistency and pedunculated (Figure 2). There is also
the partial eruption of teeth 37 and 47, necrotic pulp in
teeth 36 and 46. Radiographic examination showed a
well-defined radiolucent unilocular area related to tooth

Figure 2. Fibrous epulis in gingival region 36.

Figure 3. Panoramic radiograph showing well-defined
radiolucent unilocular area related to tooth 36
involving 1/3 middle of the root to the mesial apex,
approximately 1 cm in diameter.

The treatment comprised the extraction of the
permanent teeth involved and excisional fibrous
epulis region 36 (Figure 4-7). The cyst and fibrous
epulis were sent to the laboratory for histopathologic

examination, which confirmed the diagnosis of
radicular cyst and fibrous epulis. Post extraction and
excisional healing was uneventful (Figure 8).

DISCUSSION
A patient came with the major complain of
painless swelling on her lower left posterior region
of the mouth which causes difficulties in chewing
and eating food. This swelling is epulis based on
literature that mentioned epulis is applied to any
lump arising from gingiva.11

Figure 4. Fibrous epulis after excision.

Figure 5. After extraction of the permanent tooth involved.

Ramelya and Sutadi : Management of radicular cyst and fibrous epulis in an 11-years old girl
Jurnal PDGI 59 (3) Hal. 90-94 © 2010

Figure 6. Radicular cyst included the root of the permanent

teeth involved.

Figure 7. After suturing.

Figure 8. Control 1 week after treatment, healing was
uneventful.

From anamnesis, this painless swelling had
been there for one month and the size is small, but
has become large. Based on literature, epulis lesions
are painless, as nerves do not proliferate within the
reactive hyperplastic tissue.12 Eventhough this lesion
is painless, but its presence causes difficulties in
chewing .13
Intra oral examination, a well-defined spherical
swelling of approximately 1 cm in diameter was
noticed in the left lower gingival region 36, red in

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color, soft consistency and pedunculated. Necrotic
pulp was noticed in tooth 36. Epulis lesions are
usually round, painless, pedunculated swellings
arising from the marginal or papillary gingiva, and
sometimes adjacent to sites of irritation (e.g.
a carious cavity). They rarely involve the attached
gingiva and exceed 2 cm in diameter.11 Irritation of
the gingival margin by the sharp edge of a carious
cavity or by calculus may lead to the formation of a
fibrous epulis.2 Traumatic and inflammatory factors
constitute favorable conditions for epulises
development.13 The diagnosis is clinical but most
lesions need to be removed and examined
histologically.11
Radiographic examination showed radicular
cyst at region 36, showing a well-defined
radiolucent unilocular area related to tooth 36
involving 1/3 middle of the root to the mesial apex,
approximately 1 cm in diameter. Patient did not
notice the presence of the cyst because
asymptomatic. Radicular cysts are usually
asymptomatic and are left unnoticed, until detected
by routine radiography.3
The radicular cyst is the most common of the jaw.8,10
The associated tooth usually has a deep restoration or
large carious cavity.10 Radicular cyst at region 36 on this
patient is due to a necrotic pulp. Clinical presentation
of radicular cyst: a) asymptomatic unless there is an
acute exacerbation; b) usually a limited process at root
apex or lateral to root surface; c) radiograph shows a
round and well-defined lesion, usually with a sclerotic
margin; d) generally 1 cm or less across, but can be
significant in size, e) root resorption is uncommon. The
diagnosis were based an documentation of a nonvital
tooth and radiograph which showed alteration of apical
bone.9
The treatment comprised the extraction of the
permanent teeth involved and excisional fibrous
epulis region 36. Treatment for radicular cyst
consists of enucleation of the cyst lining coupled
with root canal treatment and, in some instances,
retrograde surgical endodontic treatment (surgical
exposure of the root apex followed by amputation
of the root apex and obturation of the opening of
the root canal), extraction of the tooth and biopsy.9,10
In this patient, due to the very large cavity and
difficulty in restoring the tooth, extraction was
decided though accepted treatment of fibrous
epulis includes the excisional biopsy, which should
be removed down to the periosteum and should
be curetted throughly.11,12

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Ramelya and Sutadi : Management of radicular cyst and fibrous epulis in an 11-years old girl
Jurnal PDGI 59 (3) Hal. 90-94 © 2010

As a conclusion, radicular cyst arised because
untreated necrotic pulp of tooth 36. The treatment
for radicular cyst is extraction of the permanent
tooth involved. Whereas fibrous epulis in this case
occurred due to chronic irritation of the gingival
margin by the sharp edge of a carious cavity, and
the treatment for fibrous epulis is excision.
Prognosis is excellent and it was expected that
recurrence will not occur.

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