|Year : 2014 | Volume
| Issue : 2 | Page : 52-55
Giant radicular cyst with bilateral maxillary sinus involvement
Emre Kose1, Emin Murat Canger1, Yildiray Sisman1, Fatma Gulfesan Yildirim Canakci2, Gulsah Cubukcu3, Hulya Akgun3
1 Department of Oral and Maxillofacial Radiology, Melikgazi, Kayseri, Turkey
2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Melikgazi, Kayseri, Turkey
3 Department of Pathology, Erciyes University, Melikgazi, Kayseri, Turkey
|Date of Web Publication||13-Aug-2014|
Emin Murat Canger
Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Erciyes University, Melikgazi, Kayseri
Source of Support: None, Conflict of Interest: None
Radicular cysts are the most common cysts of the jaws. They are localized on the apex of the teeth with necrotic pulp. They are classified as inflammatory cysts. Radiographically, they appear as an oval radiolucent lesion with well-defined radiopaque border. They develop slowly, and asymptomatic unless infected. Because of this they can reach big dimensions. Intraoral examination of an 21-year-old man revealed a fluctant swelling on the palatinal and vestibular mucosa of the incisor-canine region. Radiographic examination revealed well defined and uniformly radiolucent lesion present between the left and right molar regions. The lesion was extending to nasal cavity and left and right maxillary sinus regions. The result of the histopathological examination was reported as radicular cyst. In this report it was aimed to present a giant radicular cyst case.
Keywords: Cone beam computerized tomography, enormous odontogenic cyst, jaw lesions, radicular cyst
|How to cite this article:|
Kose E, Canger EM, Sisman Y, Yildirim Canakci FG, Cubukcu G, Akgun H. Giant radicular cyst with bilateral maxillary sinus involvement. J Oral Maxillofac Radiol 2014;2:52-5
|How to cite this URL:|
Kose E, Canger EM, Sisman Y, Yildirim Canakci FG, Cubukcu G, Akgun H. Giant radicular cyst with bilateral maxillary sinus involvement. J Oral Maxillofac Radiol [serial online] 2014 [cited 2019 Apr 20];2:52-5. Available from: http://www.joomr.org/text.asp?2014/2/2/52/138639
| Introduction|| |
The radicular cyst is the most common lesion of the maxillofacial region. It is the most frequent among, and classified as, odontogenic inflammatory cysts.  It usually grows slowly, rarely attains a large size and causes destruction of the surrounding structures. Mobility, displacement, and root resorption of the adjacent teeth are possible, especially in enlarging cysts. , It has male predilection and occurs more often in the permanent dentition than the deciduous dentition. Majority of the radicular cysts (60%) are seen in maxilla, especially in the incisor-canine region. They are commonly asymptomatic unless infected, and discovered during routine radiographic examination. ,
Radicular cysts are seen as round or ovoid uni- or multi-locular radiolucencies associated with the apex of a nonvital tooth. The radiolucencies have a radiopaque margin which extends from the lamina dura of the involved teeth. However, this margin disappears in the case of inflammation and rapid extension, accompanied by commonly observed loss of lamina dura of the adjacent teeth. ,,,
In this article, we aimed to present a case of giant radicular cyst invaded the entire left maxillary sinus major portion of the inferior nasal cavity and extending to the right maxillary sinus. We decided to introduce this report because yet to the best of our knowledge, there are precious few cases with such extension.
| Case Report|| |
A 21-year-old male was attended in our department with a major complaint of pus drainage from the anterior region of the upper jaw. His medical history was unremarkable.
Extraoral examination did not reveal any facial asymmetry. During intraoral examination, pus drainage from the gingiva between the teeth numbered 22 and 23, and discoloration and opacity on the teeth numbered 22 were observed. In addition, there were deep caries on the teeth numbered 16.
Furthermore, a fluctuant and painless swelling was extending from left canine tooth to the right molar region. It was covered with intact mucosa and more pronounced at the palatal region of the left maxillary molar region [Figure 1]. Electrical pulp test revealed that all maxillary teeth, except the numbered 22 and 16, were vital.
|Figure 1: Intraoral appearance of the painless palatal swelling (white arrows)|
Click here to view
Panoramic radiographic examination revealed a well-defined uniform radiolucent lesion extending from the maxillary right molar region to the left molar region. Its lower sclerotic border was more pronounced. The tooth numbered 22 was distally migrated. The tooth numbered 23 was deeply decayed and had a chronic periapical periodontitis at the apex of the root [Figure 2].
|Figure 2: Appearance of extend and the inferior border of the lesion (white|
arrows) on panoramic radiography
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To determine the actual extension and borders of the lesion, cone beam computerized tomography (CBCT) (Newtom 5G, QR, Verona, Italy) was utilized. In the axial, coronal, and sagittal CBCT images, a radiolucent lesion, that invaded the entire left maxillary sinus and the major portion of the inferior nasal cavity and extending to the right maxillary sinus, was detected. The approximate dimensions of the lesion were 31.7 mm × 50.6 mm [Figure 3]a and b]. It was also discovered that the radiolucent lesion at the apices of the tooth numbered 16 was not related to the huge radiolucent lesion [Figure 3]c].
The three-dimensional reconstructed CBCT images indicated that the huge lesion caused bone resorption around the roots of the teeth numbered 23, 24, and 25, and a major part of the relevant palatine [Figure 4]a and b].
|Figure 3: The, cone beam computerized tomography appearance of the|
lesion. (a) Sagittal, (b) axial, (c) coronal sections
Click here to view
|Figure 4: Three-dimensional reconstructed, cone beam computerized|
tomography appearance of the lesion. (a) Mediolateral appearance of the left
maxilla. (b) Inferior appearance of the maxilla
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The histopathological examination of the lesion specimen indicated drastic inflammation composed of plasma cells, lymphocytes, neutrophils, and leukocytes in the intraepithelial and sub-epithelial areas of the cystic structure, which was covered with multilayered squamous epithelium. This structure was reported as inflamed radicular cyst. [Figure 5].
|Figure 5: The appearance of the plasma cells, lymphocytes and neutrophile|
leukocytes in the csytic structure lined with squamous epithelium. (H and E, ×100)
Click here to view
Under general anesthesia, the patient underwent a surgical procedure that included surgical enucleation of cyst, apicoectomy and retrograde filling of involved teeth. After administration of local anesthesia, a crevicular incision was made in labial region 15-27, and a full-thickness mucoperiosteal flap was reflected. A large cyst cavity window was prepared with a rounded bur. Enucleation of the cystic lesion was performed, and it was sent for histopathological evaluation. Maxillary sinus and nasal floor perforation did not occur. Root apices of 22, 23, 24, and 25 were resected and retrogradely filled with mineral trioxide aggregate. Hemostasis was maintained by an oxidized cellulose hemostatic agent that was placed over the maxillary sinus mucosa and nasal mucosa. Flap closure was done with 3-0 Vicryl. Postoperatively the patient was kept on antibiotics and analgesics. Considering the possible irregularity in appointments, since the patient was moving to another city, where efficient health centers were not available; enucleation, instead of marsupialization, was preferred.
| Discussion|| |
It is very rare to encounter with odontogenic cysts, which have reached a very large size like in this case. Indeed odontogenic keratocyst (OKC), dentigerous cyst, and traumatic bone cyst might reach such exceptional wideness. In general, radicular cysts tend to grow slowly and do not reach large sizes. However, they may enlarge to occupy an entire quadrant of jaws. ,,, The cyst in our case reached very large dimensions by invading the major part of left maxillary sinus and extending to the right maxillary sinus. Although reflecting the nature of OKC and dentigerous cyst, interestingly this case was reported as radicular cyst. Radicular cysts are discovered either by bone deformation and inflammation, or, like in our case, by chance during routine radiographic examination. 
The radicular cysts generally grow slowly and extend either to the anatomical neighboring such as sinuses, nasal cavities, vestibule, or palate.  The extension of the odontogenic cysts to the maxillary sinuses is in relation with the proximity of the lesion to the sinuses. The type of the lesion has no effect on this extension. Infected cysts show symmetric expansion and diffuse to the spaces like sinuses or nasal cavity at the points where the bone is weak. Because of this, they remain asymptomatic and do not cause asymmetry unless sinuses are completely filled. , Similarly, the cyst in our case was extended to the maxillary sinus and nasal cavity without any symptoms.
In a large cyst, like our case, especially the one which is in relation with maxillary sinuses, panoramic radiography is not a sufficient imaging technique. CBCT has some advantages over panoramic radiography like high bone detail, detailed imagination of the dimension of the lesion and the relation of the cyst with structures such as sinuses, orbital, and nasal cavity. It is also useful in pre- and post-operative imagination of the cysts in maxillary sinuses. 
The differential diagnosis of the cysts located in maxilla is done as OKC, ameloblastoma, adenomatoid odontogenic tumor, ameloblastic fibroma, myxoma,  OKC is predominately located in the posterior body of mandible, and rarely seen in maxilla. It shows minimal bone expansion. Involved teeth are kept vital. It may have a smooth round or oval shape identical to other cysts and may be found with scalloped borders. Has internal septa which gives a multilocular appearance.  The cyst in this case had well-defined borders, it was unilocular without internal septa and had devital relevant tooth. Predominantly ameloblastoma develops in the posterior region of mandible and when occurs in maxilla, it is the third molar region. From there, it may extend to the maxillary sinus and nasal floor. Te border of the lesion is often curved. While small lesions are uniform radiolucent, greater lesions have multilocular appearance.  The lesion in our case emanated from the maxillary incisor region, and was unilocular. In opposition to the cyst in our case, adenomatoid odontogenic tumor is often associated with a missing tooth. Furthermore, internal radioopacities develop in most of the cases. Furthermore, ameloblastic fibroma usually develops in the promolar-molar area of the mandible, and usually has a relationship with a unerupted tooth. Internal structure may be multilocular. Myxoma commonly affects the posterior mandible, and when present in the maxilla, it is again found in the same region. It is usually well-defined, but most lesions present in maxilla are poorly defined. 
For a definite diagnosis, histopathological examination, pulp vitality tests, long-term follow-up, and repeated histopathological examination are useful.  In our case, all maxillary teeth responded to vitality test except numbered 22, which had been proposed as the cause of the cyst. The results of the histopathological examination of both initial incisional biopsy, and the totally excised mass were radicular cyst. Since the patient would not be able to return for follow-up, he was informed to refer to a faculty of dentistry close to the city he was living.
The treatment of the radicular cysts is determined in association with the type and volume of the lesion. Small cysts usually heal up with successful endodontic treatment. In case of huge lesions, in order to avoid possible complications like pathological fractures, first minimizing the lesion with marsupialization and later total excision is the appropriate choice of treatment. ,, Although the dimension of the lesion in our case directed us to choose marsupialization as treatment, otherwise considering the fact that the patient would not be able to go to controls, enucleation should have been chosen.
| Results|| |
With this report, it was aimed to present how a radicular cyst can show an extensive-destructive character, to emphasize the role of CBCT on diagnosis, and besides these, to give information on the treatment methods of the cystic lesion.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]