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MAXILLARY CYST: DESCRIPTION OF A CLINICAL CASEE. CIULLI, M. ROCCI, R. BOLLERO, C. PANDOLFI, L. OTTRIA, G. MAMPIERI, A. BARLATTANI Jr., P. BOLLERO

Department of Odontostomatological Science, University of Rome “Tor Vergata”

SUMMARYMaxillary cyst: description of a clinical caseAim of the work. Aim of this work is to evaluate the ef-ficacy of the Partsch I surgical technique which is con-sidered to be first choice in the treatment of cystic le-sions according to the international literature and also toevaluate the regeneration capacity of the bone tissuewithout any grafting procedure.Materials and methods. The patient reported pain inthe second quadrant. The objective intraoral examina-tion showed a swelling which was of a hard-elastic con-sistency and, the x-ray, opt and ct scan exams showedan osteolitic lesion which expanded from the element2.3 to the elment 2.6 involving the maxillary sinus, too.The lesion was removed by the Partsch I method afterdisinfecting and shaping the radicular canals of the 2.3element. It was assessed that the maxillary sinus re-quested no treatment for the presence of a thin corticallayer residue. The removed neoformation was then sentto the Anatomy and Histology Pathology Service.Results. The histologic test confirmed the radicular ori-gin of the odontogenic neoformation containing a necrot-ic-hemorrhage. Clinically the post-operative courseshowed no complications, with a good healing of thebone tissue and there was no oral-antral communica-tions.Conclusions. The clinical results obtained confirmedthe validity of the enucleation technique in the treatmentof cystic neoformations. Such approach has always tobe preferred because it presents no intraoperative risks,especially for what it concerns the post-operativecourse. It has also been confirmed the great capacity forthe bone tissue to regenerate following the organizationof the hematic coagulum.

Key words: cyst, enucleation.

RIASSUNTOCisti dei mascellari: descrizione di un caso clinicoScopo del lavoro. Lo scopo del lavoro è di valutarel’efficacia della tecnica chirurgica Partsch I, consideratadalla letteratura internazionale la prima scelta nel tratta-mento delle lesioni cistiche; è altresì importante valutarela capacità di rigenerazione del tessuto osseo, in assen-za di procedure di grafting.Materiali e metodi. Il paziente giunto alla nostra osser-vazione lamentava sintomatologia algica in corrispon-denza del II quadrante. L’esame obiettivo intraorale evi-denziava una tumefazione di consistenza duro-elastica egli esami Rx OPT e TC mostravano una lesione osteoli-tica che si estendeva dall’elemento 2.3 all’elemento 2.6con interessamento del seno mascellare. Si procedevadunque alla rimozione della lesione mediante tecnicaPartsch I, previa disinfezione e sagomatura dei canali ra-dicolari dell’elemento 2.3. Non si riteneva necessario al-cun trattamento del seno mascellare per la presenza diun sottile strato di corticale residua. La neoformazioneasportata veniva inviata al Servizio di Anatomia ed Isto-logia Patologica. Risultati. L’esame istologico confermava l’origine radi-colare della neoformazione odontogena, a contenuto ne-crotico-emorragico. Clinicamente, il decorso post-opera-torio si mostrava privo di complicanze, con una buonaguarigione del tessuto osseo, in assenza di comunica-zioni oro-antrali.Conclusioni. I risultati clinici ottenuti confermavano lavalidità della tecnica di enucleazione nel trattamento del-le neoformazioni cistiche; in assenza di rischi intraopera-tori, infatti, tale approccio è sempre da preferire, soprat-tutto in riferimento al decorso post-operatorio. Era altre-sì confermata l’ottima capacità di rigenerazione del tes-suto osseo in seguito all’organizzazione del coaguloematico.

Parole chiave: cisti, enucleazione.

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Introduction

Maxillary cysts are pathologic cavities with a liq-uid or semiliquid content delimited wholly orpartially by epithelium; the origin of the latterone allows to distinguish cysts in odontogenic ornonodontogenic. The former, which are more fre-quent, are characterized by a layer of the epithe-lium deriving from the residues in which thetooth forms itself; being more specific, the Serresglands which persist even after the dissolution ofthe dental lamina, the enamel epithelium and theMalassez residues formed by the fragmentationof the Hertwig epithelial sheath. The activationof these residues by a degenerative mechanism isnot completely clear but can be led to processesof an inflammatory kind or to phenomena of con-genital nature (3, 13). Cystic lesions, though be-nigne and often asymptomatic, can be character-ized by a tendency to grow at the expense of theother surrounding structures so that a treatmentof surgical type is required. The techniques de-scribed in literature (1, 3) are mainly the enucle-ation (Partsch I) and the marsupialization of thelesion (Partsch II) or a combination of the two.Enucleation is the first choice treatment; shouldit involve serious intra-operative risks a differenttechnique has to be opted for. Particular largeneoformations at the expense of the bone compo-nents, with a risk of fracturing them or very closeto important anatomical structures represent theprincipal conditions for a surgical approach withthe Partsch II technique.

Peculiar features of the radicular cysts

Radicular cysts are considered to be lesions of anodontogenic nature which originate from the ep-ithelial residues present in the parodontiumspace, and its proliferation is activated by an in-flammatory-type mechanism. As a consequenceof the necrosis of a dental element, the batterial

and necrotic residues of the pulp reach the rootapices and the parodontium space, where are fre-quently present the residual cells of the Hertwigsheath (residues of Malassez); these are incited toproliferate and form a column like epithelial cellsin the periapical area (3-5, 10). According to theliterature (7, 2, 6, 12, 13), the mechanism whichsustains the growth of the cystic lesion could it bedouble; the most reliable theory is called the hy-drostatic theory: within the proliferating epithe-lial cells there is a build-up of other residues(protein, cholesterol) and the relative increase ofthe osmotic pressure results in fluid accumula-tion; the increase in the hydrostatic pressure de-termines an osteoclastic activation and thus aprogressive expansion of the lesion at the ex-pense of the surrounding bone structure. Theprostaglandinic theory, instead, supports the os-teoclastic activation by the proglandine andprostacicline present in the cystic wall. It is prob-able that both mechanisms contribute to the for-mation and development of such a lesion.

Clinical and radiographicalcharacteristics

The radicular cyst is the most common cystic le-sion, with a frequency of about 50% amongst allcystic lesions of odontogenic nature (3). In mostcases it is diagnosed accidentally while taking nor-mal radiographic tests. As such lesions are typical-ly asymptomatic, the clinical diagnoses is ratherrare unless the cyst reaches such dimensions as toerode the cortical bones or flogistic processesspring up. A rather useful indication to address thediagnoses is the vitality test, as a radicular cyst isalways associated with a necrotic dental element(3, 4, 10, 11). From a radiographic point of view,this neoformation appears as a unilucular radio-transparency with very clear margins with aroundish shape still in relation with the radicularapex (9). From a histologic point of view is cov-ered by a stratified squamous epithelium unkera-tinized (5, 8, 13).

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Materials and methods

Clinical case

A 65-year-old male patient presenting an algicsymptomatology corresponding to the upper leftarch came to our attention. To an objective intra-oral examination a tumefaction of a hard elasticconsistency was detected, with the entire mucosaabove and of a normal color (Fig. 1). An OPT (Fig.5) and denta scan examination (Figs. 2-4) was re-quested in which an osteolitic lesion appeared ex-tended to the maxillary sinus, too. The patient un-derwent a thorough anamnesis and informed about

the possible therapeutic solutions. It has been opt-ed for a surgical approach through the enucleationof the lesion (Partsch I technique).

Clinical procedure

After having verified the necrosis of the 2.3 ele-ment, cleaning and shaping of the root canal wasperformed on the same tooth and with the neofor-mation being removed. After having anaes-thetised the second region and by blocking theinfraorbital nerve, a mucoperiosteal flap was pre-pared through an intrasulcular and crestal inci-sion stretching from the element 2.3 to 2.6 withtwo releasing incisions, mesially to the canine

Figure 2 Axial scan.

Figure 4 Oblique cross-sections.

Figure 1 Vestibular swelling. Figure 3

Tc panorex.

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and distally to the first molar (Fig. 6). After rais-ing the flap, in which it was possible to see theerosion of the vestibular cortical bone by the neo-

formation, its remotion was performed by usingperiosteal elevators (Fig. 7). The analysis of thecavity detected the presence of a thin layer ofresidual cortical bone, which insured the integri-ty of the maxillary sinus and any other treatmentwas superfluous (Figs. 8 a, b). After curettage ofthe cavity washes were done with hydrogen per-oxide and hemostasis and sutured 3.0 silk sutures(Fig. 9). It was then performed a local infiltrationin the buccinator muscle of Bentelan (4 mg/2 ml)and prescribed an antibiotic therapy of Aug-mentin for six days, an antiflogistic therapy andanalgesics when needed and mouthwashes withclorhexidine 0.2%. The removed neoformationwas then sent to the Pathological and Anatomy &Histology Services.

Figure 6 Mucoperiosteal flap setting and exposure cystic neo-plasm.

Figure 7 Radicular cyst.

Figure 5 Radiographic orthopanoramic.

Figure 8 a, bResidual bone cavity.

A B

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Discussion and conclusions

The histological examination confirmed the in-flammatory nature of the lesion which was 2.5 × 1× 0.3 cm big. The radicular type cyst and of odon-togenic origin, showed a hemorragic-necrotic con-tent including cholesterol crystals. The clinicaland radiographic checks done after surgeryshowed a postoperative course without complica-tions. The soft tissues showed an excellent healingand the radiographic tests (Fig. 10) showed the ab-sence of oro-antral communication due to thegradual filling of the cavity by the new formingbone tissue; the presence of the haematic clotformed soon after surgery has secured the alterna-tion of those biological phenomena which hesitatein the formation of new bone. Blood clot, contract-ing, yielded the way to the formation of granula-tion tissue, characterised by new blood vessels andyoung collagen fibres; subsequently, the reorgani-zation of this tissue hesitated in forming osteoidtrabeculas which, starting from the bone walls,were heading towards mineralization processes.The good healing of the surgical site, witnessed byboth clinical and radiographic follow-ups, indeedconfirm that the enucleation technique has to bepreferred every time important intraoperative risksare not expected, such as the fracture of the bonecomponents or the lesion of the anatomical struc-tures. As the international literature maintains, the

Partsch I surgical technique allows a postoperativecourse little uncomfortable for the patient and inthe vast majority of cases without any complica-tion worth noting. This kind of approach guaran-tees a healing of the soft tissues as first intentionand, thanks to the formation of blood clotting, se-cures those biological mechanisms as proof of theautonomous regenerative capability of the bonetissue, without using any grafting material.

References

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Figure 9 Hemostasis and suture.

Figure 10 Orthopanoramic monitoring.

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Correspondence to: Dott.ssa Carola Pandolfi Tel. 3333629208E-mail: carola_pandolfi@yahoo.it