For fifteen years, the man had not visited a dentist. After falling as a teenager, he allowed his tooth to become discolored, his gums to swell, and only sought treatment at the Dental Hospital of Universitas Padjadjaran when the pain became unbearable—particularly when he was physically exhausted. At the age of 32, what doctors discovered went far beyond their initial expectations: a cyst that had grown silently, destroying the bone of the palate and even penetrating the floor of his nasal cavity.
This case report was documented by drg. Silviana Farrah Diba, Sp.RKG. Subsp. RP(K), from the Department of Dental Radiology, Faculty of Dentistry, Universitas Gadjah Mada, together with colleagues from Universitas Padjadjaran, and was published in the December 2019 issue of the Jurnal Radiologi Dentomaksilofasial Indonesia.
A Darkened Tooth, a Pus-Filled Gum, and a Hidden Mystery
The initial clinical examination revealed that the upper left central incisor (tooth 21) was darker than the adjacent teeth. A hard swelling was present on the palatal side, the tooth was slightly mobile, and the vitality test was negative—an indication that the pulp tissue inside the tooth had died.
An initial periapical radiograph showed a well-defined radiolucent area at the root apex of tooth 21, extending toward tooth 22. This appearance was characteristic of a radicular cyst, a pathological fluid-filled sac that develops as a result of chronic inflammation associated with necrotic tissue around the root apex.
What could not be seen on the two-dimensional radiograph was the actual extent of the cyst.
When Two-Dimensional Imaging Is No Longer Enough
This is where Cone Beam Computed Tomography (CBCT) played an important role.
Unlike conventional dental radiographs, which display a flat projection, CBCT reconstructs images in three planes simultaneously: coronal, sagittal, and axial. There is no superimposition of anatomical structures and minimal distortion. Each slice can be examined individually, with the viewing angle adjusted according to clinical needs.
The findings in this case were surprising. Three-dimensional reconstruction revealed a much more extensive osteolytic lesion, or bone destruction, than initially suspected. The cyst not only involved the area surrounding the root of tooth 21 but had also destroyed the labial cortical bone on the front side, the palatal cortical bone, and, most seriously, had penetrated the floor of the left nasal cavity. The largest lesion dimensions measured 17.9 × 14.3 mm on the sagittal view.
“Perforation of adjacent anatomical structures can occur in large cysts; therefore, adequate radiographic examination is necessary to determine the effects of the lesion on surrounding tissues, establish a diagnosis, and plan surgery.” — drg. Silviana Farrah Diba, Sp.RKG. Subsp. RP(K) and colleagues, in the case report
The two-dimensional periapical radiograph had shown a second suspicious dark area, suspected to represent palatal perforation. CBCT definitively confirmed the suspicion.
From Diagnosis to the Operating Room
After endodontic treatment had been completed, CBCT was performed to provide comprehensive mapping before surgery. This was not a decision made casually: CBCT involves a higher radiation dose than conventional dental radiographs, so its use should be carefully considered based on clear clinical indications.
The surgical treatment included apicoectomy (removal of the root apex), cyst enucleation (complete removal of the cystic sac), bone graft placement to fill the resulting bony defect, and tooth whitening to restore aesthetics. Histopathological examination subsequently confirmed the diagnosis, revealing fibrous connective tissue, inflammatory cells, and areas of necrosis—findings characteristic of a long-standing radicular cyst.
Three months after treatment, a follow-up periapical radiograph showed that the cyst's sclerotic border had begun to fade. New bone was forming from the edges toward the center of the lesion, indicating that healing was progressing appropriately.
Lessons from a Case That Was Nearly Missed
Radicular cysts are known to grow very slowly and often produce few or no symptoms. Many patients are unaware of their presence until the lesion becomes large or is discovered incidentally during routine examination. This case serves as a stark reminder: a history of dental trauma that is ignored for years can eventually result in structural damage extending far beyond the tooth itself.
The report also emphasizes that CBCT is not a replacement for conventional radiographs, but rather a confirmation and planning tool when the size or location of a lesion is uncertain. For postoperative evaluation in this case, a conventional periapical radiograph was considered sufficient—a reminder that even advanced technology should be used proportionately and according to genuine clinical needs.
The cyst had remained silent for more than a decade. What ultimately led to its detection was not simply more advanced technology, but the decision to finally seek dental care.
Source DOI: DOI: 10.32793/jrdi.v3i3.439
Authors: Anny Anggraini; drg. Achmad Zam Zam Aghasy, M.Kes.
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