Endoscopic Surgical Treatment of Maxillary Odontogenic Cysts€¦ · Management of maxillary...
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Poster Design & Printing by Genigraphics ® - 800.790.4001 INTRODUCTION CONCLUSIONS DISCUSSION REFERENCES ABSTRACT CONTACT Objective Management of maxillary odontogenic cysts consists of transoral resection or curettage. Large lesions require extensive dissection, leading to perioperative morbidity and need for extensive reconstruction. 1. Describe the use of transnasal endoscopic marsupialization for the management of maxillary odontogenic cysts. 2. Understand this approach can minimize morbidity with effective treatment. Methods Case series. Endoscopic sinus surgical techniques were used to treat large benign maxillary odontogenic cysts in five patients between June 2008 and October 2011. Results Patients underwent endoscopic marsupialization after creation of a wide maxillary antrostomy. Molars associated with the cystic lesions were displaced into portions of the maxillary sinus in two cases. The molars were dissected and removed through the transnasal dissection in each of these cases. Histological and radiological findings were consistent with 1 odontogenic keratocyst, 3 dentigerous cysts and 1 radicular cyst. The lesions were able to be marsupialized endoscopically with relief of the patient's initial symptoms and no recurrence. Follow up has shown an excellent functional outcome in all cases. Conclusion Benign maxillary odontogenic cysts can be effectively treated using transnasal endoscopic approaches. The techniques are less invasive and can reduce morbidity compared to transoral techniques. Kunal Jain, MD [email protected] Parul Goyal, MD [email protected] Maxillary odontogenic cysts have traditionally been treated using surgical approaches such as enucleation, curettage, maxillectomy, and tooth extraction. 1-3 These procedures require a transoral incision and most of the affected teeth are extracted along with the cyst walls. Potential morbidity includes oroantral fistulas, need for extensive reconstruction, loss of surrounding dentition, and chronic rhinosinusitis. This series describes the use of an endoscopic intranasal approach for the management of large maxillary odontogenic cysts with an aim to reduce these complications and morbidity. To illustrate the technique the preoperative CT images (Figure 1) and intraoperative endoscopic images of a patient are displayed below. Figure 1: Preoperative coronal CT image showing complete opacification of left maxillary sinus with an expansile lesion and a displaced maxillary molar along the infraorbital floor. SURGICAL TECHNIQUE Figure 3 Figure 4 Figure 2 -Nasal endoscopy performed with 0 degree and 30 degree scope to evaluate middle meatus (Figure 2, 3) -A wide maxillary antrostomy is performed with removal of the uncinate process using a backbiter and microdebrider (Figure 3) -The unattached portion of the maxillary cyst is delivered from the lateral and anterior aspect of the sinus and debulked using a microdebrider, curettes and non- cutting instruments (Figure 4) -To access the inferior portion of the maxillary sinus the middle meatal maxillary antrostomy is extended by resecting the mid portion of the inferior turbinate and removal of the medial maxillary sinus wall along the inferior meatus -A wide communication is created into the nasal cavity by removing the medial wall of the cyst -A down biter is used to extend the opening of this odontogenic cyst down to the level of the nasal floor -The roof of the cyst and its posterior extent are removed transnasally along with impacted teeth (Figure 5). The impacted teeth are often displaced superiorly into the sinus and can be dissected and extracted through the transnasal dissection (Figure 6). -A 70 degree diamond burr is used to drill down the osteitic bone between the maxillary sinus and the cyst -Post-operative view showing healing maxillary mega-antrostomy. The sinus remains widely patent for post- operative surveillance (Figure 7). Figure 6 Figure 5 Kunal Jain MD, Parul Goyal MD Department of Otolaryngology, SUNY Upstate Medical University and the Syracuse VA Medical Center, Syracuse, NY Endoscopic Surgical Treatment of Maxillary Odontogenic Cysts Treatment of large maxillary odontogenic cysts can be difficult. Often, extensive transoral approaches are used to curette or enucleate these lesions. Very large lesions have sometimes required maxillectomy. In this series, large maxillary odontogenic lesions were managed by using transnasal endoscopic techniques. In these cases, a wide maxillary opening is created through removal of the entire medial wall of the maxillary sinus. This allows the majority of the cyst lining to be removed. Any small remnants of the odontogenic lesion are marsupialized into the maxillary sinus to prevent further cyst expansion. The advantage of marsupialization via a transnasal approach is that any material produced by the residual cyst lining is able to be cleared with nasal hygiene measures. The technique also allows for continued endoscopic surveillance over the long term. Follow up has shown an excellent functional outcome and no recurrence in any of the patients presented. The removed cyst lining is examined histologically to assess for any associated neoplastic processes. The presence of a neoplasm may necessitate additional resection. The transnasal endoscopic approach outlined in this poster avoids the complications and morbidity of traditional procedures including oroantral fistulas, chronic maxillary sinusitis, loss of dentition and effects on maxillary bone growth and eruption of permanent teeth in children. 4 In addition, this approach eliminates the need for extensive maxillary reconstruction that may be required with traditional maxillectomy techniques. Benign maxillary odontogenic cysts can be effectively treated using transnasal endoscopic approaches. The techniques are less invasive and can reduce morbidity and complications compared to maxillectomy or transoral techniques. 1. Deboni MC, Brozoski MA, Traina AA et al. Surgical management of dentigerous cyst and keratocystic odontogenic tumor in children: a conservative approach and 7-year follow-up. J Appl Oral Sci 2012, 20:282-5 2. Koca H, Esin A, Aycan K. Outcome of dentigerous cysts treated with marsupialization. J Clin Pediatr Dent 2009 34:165-8 3. Pogrel MA, Jordan RC. Marsupialization as a definitive treatment for the odontogenic keratocyst. J Oral Maxillofacial Surg 2004, 62:651-5 4. Seno S, Ogawal T, Shibayama M et al. Endoscopic sinus surgery for the odontogenic maxillary cysts. Rhinology 2009, 47:305-309 METHODS AND RESULTS Patient Age at presentation Lesion type Management Follow up (months) 1 50 Radicular cyst Maxillary mega- antrostomy 36 2 33 Dentigerous cyst Maxillary mega- antrostomy 60 3 59 Dentigerous cyst Maxillary mega- antrostomy 27 4 39 Dentigerous cyst Maxillary mega- antrostomy 48 5 18 Odontogenic keratocyst Maxillary mega- antrostomy 30 A retrospective review was performed of patients treated with endoscopic surgical techniques for large maxillary odontogenic cysts. Patients presented with nasal obstruction, facial pressure and swelling, and rhinorrhea. No recurrences were seen with a mean follow up period of 40 months. Figure 7
Transcript of Endoscopic Surgical Treatment of Maxillary Odontogenic Cysts€¦ · Management of maxillary...
Poster Design & Printing by Genigraphics® - 800.790.4001
INTRODUCTION
CONCLUSIONS
DISCUSSION
REFERENCES
ABSTRACT
CONTACT
ObjectiveManagement of maxillary odontogenic cysts consists of transoral resection or curettage. Large lesions require extensive dissection, leading to perioperative morbidity and need for extensive reconstruction.1. Describe the use of transnasal endoscopic marsupialization for the management of maxillary odontogenic cysts.2. Understand this approach can minimize morbidity with effective treatment.
MethodsCase series. Endoscopic sinus surgical techniques were used to treat large benign maxillary odontogenic cysts in five patients between June 2008 and October 2011.
ResultsPatients underwent endoscopic marsupialization after creation of a wide maxillary antrostomy. Molars associated with the cystic lesions were displaced into portions of the maxillary sinus in two cases. The molars were dissected and removed through the transnasal dissection in each of these cases. Histological and radiological findings were consistent with 1 odontogenic keratocyst, 3 dentigerous cysts and 1 radicular cyst. The lesions were able to be marsupialized endoscopically with relief of the patient's initial symptoms and no recurrence. Follow up has shown an excellent functional outcome in all cases.
ConclusionBenign maxillary odontogenic cysts can be effectively treated using transnasal endoscopic approaches. The techniques are less invasive and can reduce morbidity compared to transoral techniques.
Kunal Jain, [email protected]
Parul Goyal, [email protected]
Maxillary odontogenic cysts have traditionally been treated using surgical approaches such as enucleation, curettage, maxillectomy, and tooth extraction.1-3 These procedures require a transoral incision and most of the affected teeth are extracted along with the cyst walls. Potential morbidity includes oroantral fistulas, need for extensive reconstruction, loss of surrounding dentition, and chronic rhinosinusitis. This series describes the use of an endoscopic intranasal approach for the management of large maxillary odontogenic cysts with an aim to reduce these complications and morbidity. To illustrate the technique the preoperative CT images (Figure 1) and intraoperative endoscopic images of a patient are displayed below.
Figure 1: Preoperative coronal CT image showing complete opacification of left maxillary sinus with an expansile lesion and a displaced maxillary molar along the infraorbital floor.
SURGICAL TECHNIQUE
Figure 3
Figure 4
Figure 2
-Nasal endoscopy performed with 0 degree and 30 degree scope to evaluate middle meatus (Figure 2, 3)
-A wide maxillary antrostomy is performed with removal of the uncinate process using a backbiter and microdebrider (Figure 3)
-The unattached portion of the maxillary cyst is delivered from the lateral and anterior aspect of the sinus and debulked using a microdebrider, curettes and non-cutting instruments (Figure 4)
-To access the inferior portion of the maxillary sinus the middle meatal maxillary antrostomy is extended by resecting the mid portion of the inferior turbinate and removal of the medial maxillary sinus wall along the inferior meatus
-A wide communication is created into the nasal cavity by removing the medial wall of the cyst
-A down biter is used to extend the opening of this odontogenic cyst down to the level of the nasal floor
-The roof of the cyst and its posterior extent are removed transnasally along with impacted teeth (Figure 5). The impacted teeth are often displaced superiorly into the sinus and can be dissected and extracted through the transnasal dissection (Figure 6).
-A 70 degree diamond burr is used to drill down the osteitic bone between the maxillary sinus and the cyst
-Post-operative view showing healing maxillary mega-antrostomy. The sinus remains widely patent for post-operative surveillance (Figure 7).
Figure 6
Figure 5
Kunal Jain MD, Parul Goyal MDDepartment of Otolaryngology, SUNY Upstate Medical University and the Syracuse VA Medical Center, Syracuse, NY
Endoscopic Surgical Treatment of Maxillary Odontogenic Cysts
Treatment of large maxillary odontogenic cysts can be difficult. Often, extensive transoral approaches are used to curette or enucleate these lesions. Very large lesions have sometimes required maxillectomy.
In this series, large maxillary odontogenic lesions were managed by using transnasal endoscopic techniques. In these cases, a wide maxillary opening is created through removal of the entire medial wall of the maxillary sinus. This allows the majority of the cyst lining to be removed. Any small remnants of the odontogenic lesion are marsupialized into the maxillary sinus to prevent further cyst expansion. The advantage of marsupialization via a transnasal approach is that any material produced by the residual cyst lining is able to be cleared with nasal hygiene measures. The technique also allows for continued endoscopic surveillance over the long term. Follow up has shown an excellent functional outcome and no recurrence in any of the patients presented. The removed cyst lining is examined histologically to assess for any associated neoplastic processes. The presence of a neoplasm may necessitate additional resection.
The transnasal endoscopic approach outlined in this poster avoids the complications and morbidity of traditional procedures including oroantral fistulas, chronic maxillary sinusitis, loss of dentition and effects on maxillary bone growth and eruption of permanent teeth in children.4 In addition, this approach eliminates the need for extensive maxillary reconstruction that may be required with traditional maxillectomy techniques.
Benign maxillary odontogenic cysts can be effectively treated using transnasal endoscopic approaches. The techniques are less invasive and can reduce morbidity and complications compared to maxillectomy or transoral techniques.
1. Deboni MC, Brozoski MA, Traina AA et al. Surgical management of dentigerous cyst and keratocystic odontogenic tumor in children: a conservative approach and 7-year follow-up. J Appl Oral Sci 2012, 20:282-5
2. Koca H, Esin A, Aycan K. Outcome of dentigerous cysts treated with marsupialization. J Clin Pediatr Dent 2009 34:165-8
3. Pogrel MA, Jordan RC. Marsupialization as a definitive treatment for the odontogenic keratocyst. J Oral Maxillofacial Surg 2004, 62:651-5
4. Seno S, Ogawal T, Shibayama M et al. Endoscopic sinus surgery for the odontogenic maxillarycysts. Rhinology 2009, 47:305-309
METHODS AND RESULTS
Patient Age at presentation
Lesion type Management Follow up (months)
1 50 Radicular cyst Maxillary mega-antrostomy
36
2 33 Dentigerous cyst Maxillary mega-antrostomy
60
3 59 Dentigerous cyst Maxillary mega-antrostomy
27
4 39 Dentigerous cyst Maxillary mega-antrostomy
48
5 18 Odontogenic keratocyst
Maxillary mega-antrostomy
30
A retrospective review was performed of patients treated with endoscopic surgical techniques for large maxillary odontogenic cysts. Patients presented with nasal obstruction, facial pressure and swelling, and rhinorrhea. No recurrences were seen with a mean follow up period of 40 months.
Figure 7
![Short Case Report · Calcifying odontogenic cysts (COCs), or Gorlin’s cysts, are rare lesions that account for less than 1% of all odontogenic cysts [1]. This article details two](https://static.fdocuments.net/doc/165x107/5fea60342725d22f6c4de3eb/short-case-report-calcifying-odontogenic-cysts-cocs-or-gorlinas-cysts-are.jpg)
