**5. Cyst treatment options**

**Marsupialization** (Partsch I) procedure is a technique for making a surgical incision in the cyst capsule, minimizing intracystic pressure, and evacuating its contents, then suturing the edges of the cyst to the healthy surface of the oral mucosa to establish a large permanent opening (Figure 7).[17]

**Decompression** is a technique that relieves the pressure within the cyst by making a small opening in the cyst and keeping it open. This can be achieved with a drain or obturator. Each day the obturator should be removed and the cyst cavity should be irrigated. The cyst size will decrease and any damage to important structures upon enucleation will be diminished (Figures 8, 9). [18]

The decompression and marsupialization of cysts were first suggested by Partsch in the German literature in the late 19th century. [18] Indications for such marsupialization and decompression are large cysts with thin bony walls that may cause spontaneous fracture, cysts that are very close to structures such as the n. alveolaris inferior or nasal floor, and infected cysts. [17, 18, 19]

**Enucleation** (Partsch II procedure) is a procedure in which all pathological tissue is removed and wound edges are closed (Figure 10). [18]

**Figure 7.** Marsupialization (Partsch I) procedure of a ranula.

**4. Etiology of cysts localized in the maxillary sinus**

length 23 mm, 3. Anteroposterior length 34 mm.

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A cyst is a lesion consisting of an epithelial sac, filled with fluid or semisolid material, and is surrounded by a connective tissue capsule. Cysts are more commonly seen in the maxilla than the mandible. The most common causes of cysts localized in the maxillary sinus are chronic infection, allergic sinonasal disease, trauma, previous surgery, obstruction of the sinus ostium, accumulations of secretions, ectopic teeth, foreign bodies (e.g., dental implant, tooth roots, graft materials), dental infections, incomplete sealing of all communications between the root canal system and periradicular tissues during endodontic treatment, mechanical obstruction of mucociliary flow, defects in ciliary capabilities to propel the mucous blanket and genetic factors. Pathologically, a cyst can develop and grow in the sinus until it reaches a large size

**Figure 5.** The sinus maxillaries. Volume ~15 cc and pyramidal shape. 1. inferosuperior length 33 mm, 2. Mediolateral

with no serious complaint by the patient because of the anatomy of the sinus. [14-16]

**Figure 8.** Decompression technique for a dentigerous cyst.

**Figure 9.** Enucleation after 12 months of decompression.

**Figure 8.** Decompression technique for a dentigerous cyst.

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**Figure 10.** Enucleation (Partsch II procedure) of an odontogenic keratocyst.

## **6. Cases**

#### **6.1. Case 1**

A 19-year-old male was referred to our department of oral and maxillofacial surgery with a 3 week history of swelling on the right side of the face. There was no history of trauma, pain, paresis, paresthesia, or lymphadenopathy. There was slight but obvious facial asymmetry caused by the swelling over the right maxillary region. The mass was firm and non-tender on palpation and not adherent to the overlying skin. Intra-oral examination showed little expansion of the upper right third molar region.

A panoramic radiograph and CT showed a well-defined unilocular radiolucency involving the right maxillary sinus along with the impacted third molar in the top part of the maxillary sinus in conjunction with the orbital floor. A vitality test was performed; all the teeth were vital.


**Figure 11.** Panoramic radiograph and CT views.

**Figure 10.** Enucleation (Partsch II procedure) of an odontogenic keratocyst.

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expansion of the upper right third molar region.

A 19-year-old male was referred to our department of oral and maxillofacial surgery with a 3 week history of swelling on the right side of the face. There was no history of trauma, pain, paresis, paresthesia, or lymphadenopathy. There was slight but obvious facial asymmetry caused by the swelling over the right maxillary region. The mass was firm and non-tender on palpation and not adherent to the overlying skin. Intra-oral examination showed little

A panoramic radiograph and CT showed a well-defined unilocular radiolucency involving the right maxillary sinus along with the impacted third molar in the top part of the maxillary sinus in conjunction with the orbital floor. A vitality test was performed; all the teeth were

**6. Cases**

**6.1. Case 1**

vital.

In cases like this, careful examination is important. Points that should be checked include possible obstruction of the sinus ostium (Figures11, 12), the need for an antrostomy procedure, the route of the canalis nasolacrimalis, resorption of the posterior bony wall of the sinus, continuity of the orbital floor, and eye examinations before and after the operation. In such operations where visualization is a problem, an endoscopic-assisted approach is mandatory. [20] Endoscopic sinus surgery has been performed for various indications in maxillofacial surgical practice. It has been used for the assessment of antral pathologies, removal of foreign bodies, orthognathic procedures, and the treatment of facial fractures. [21, 22] Especially after finishing the removal of a cyst and tooth in operations like this using endoscopy, the surgeon should check any remaining pathology of the cyst, continuity of the orbital floor, to assess the possibility of a blow-out fracture [23], root tips of the teeth and any possible damage, check the aperture of sulcus nasolacrimalis, and perform an antrostomy using endoscopic assistance as needed. [24]

The operation was performed under general anesthesia, combined with local anesthesia. A mucoperiosteal flap was opened in two layers (Figure 13). Through a modified Caldwell-Luc approach, the cyst was exposed (Figure 14). At this stage in the operation, saving teeth vitality is the most important point, so it is important to work at least 5 mm away from the teeth apices. After the pus was removed from the cyst, the tooth was carefully extracted under endoscopic assistance and the remaining part of the cyst was then enucleated (Figure 15, 16). Using endoscopy, the cavity was checked (Figure 17) and packing of the sinus (Figure 18) was performed; this was removed 3 days later. Vitality of the teeth were checked for the last time at 3 months after the operation and all teeth were vital.

**Figure 12.** Panoramic radiograph, lateral cephalometric and CT views showing tooth in the right maxillary sinus.

**Figure 13.** Mucoperiosteal flap preparation.

**Figure 12.** Panoramic radiograph, lateral cephalometric and CT views showing tooth in the right maxillary sinus.

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**Figure 14.** Exposure of the cyst. Endoscopic view (right).

**Figure 15.** Enucleation of the cyst.

**Figure 16.** Extraction of the tooth.

**Figure 17.** Postoperative cavity checking.

**Figure 15.** Enucleation of the cyst.

250 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Figure 16.** Extraction of the tooth.

**Figure 18.** Packing of the sinus after antrostomy.

#### *6.1.1. Intranasal inferior meatal antrostomy technique*

An intranasal inferior meatal antrostomy is a process of making an opening in the nasoantral wall of the inferior meatus by an intranasal route. The nasoantral wall of the inferior meatus is perforated with a curved hemostat and then this opening is enlarged. The opening should be 1.5-2 cm in diameter and as close to the floor of nose as possible (Figure 19). Intrasinus pus/ debris should be removed by suction. Packing into the sinus is achieved from the posterior, packing layer-by-layer upwards and forwards (to facilitate removal through the antrostomy) and nose packing may also be required if there is severe bleeding (Figure 20). [25]

**Figure 19.** Intranasal inferior meatal antrostomy technique.

**Figure 20.** Packing of the sinus maxillaris.

#### **6.2. Case 2**

During an incidental radiological exam (orthopantomograph, OPG, Figure 21 at our depart‐ ment of radiology, a 51-year-old male with no complaints and no history of any trauma, pain, paresis, paresthesia, or lymphadenopathy, was discovered to have an ectopic tooth in the right maxillary antrum. A CT scan (Figure 21) was performed and all important points were checked. An operation was performed under general anesthesia with combined local anes‐ thesia. Using a crestal incision, a trapezoid mucoperiosteal flap was designed and carefully elevated. The tooth was extracted under endoscopic assistance (Figures 22, 23) and a dentig‐ erous cyst was enucleated (Figure 24). Using endoscopy, all cavities were checked and packing of the sinus was performed; this was then removed 3 days later.

**Figure 21.** OPG and CT views.

is perforated with a curved hemostat and then this opening is enlarged. The opening should be 1.5-2 cm in diameter and as close to the floor of nose as possible (Figure 19). Intrasinus pus/ debris should be removed by suction. Packing into the sinus is achieved from the posterior, packing layer-by-layer upwards and forwards (to facilitate removal through the antrostomy)

During an incidental radiological exam (orthopantomograph, OPG, Figure 21 at our depart‐ ment of radiology, a 51-year-old male with no complaints and no history of any trauma, pain,

and nose packing may also be required if there is severe bleeding (Figure 20). [25]

**Figure 19.** Intranasal inferior meatal antrostomy technique.

252 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Figure 20.** Packing of the sinus maxillaris.

**6.2. Case 2**

**Figure 22.** Extraction under endoscopic assistance.

**Figure 23.** Extraction under endoscopic assistance.

**Figure 24.** Enucleated dentigerous cyst.

#### **6.3. Case 3**

**Figure 22.** Extraction under endoscopic assistance.

254 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

A 23-year-old female was referred to our department of oral and maxillofacial surgery with headache, fatigue, and difficulty in nasal breathing. After a radiological examination (figure 25), it was seen that there was an ectopic third molar in the left sinus and a wisdom lower left third molar in conjunction with a cyst. A CT scan (Figure 26) was performed and all important points were checked and it was seen that the third molar in the maxillary sinus was associated with a cyst that had occupied over two-thirds of the left maxillary sinus.

An operation was performed under general anesthesia with combined local anesthesia. A trapezoid mucoperiosteal flap was designed and carefully elevated (Figure 27). The tooth was extracted (Figure 28) and the cyst was enucleated (Figure 29). An intranasal inferior meatal antrostomy was performed with packing of the sinus (Figure 30); this was removed 3 days later. After the operation, all symptoms of headache, fatigue, and difficulty in nasal breathing resolved. Pathological specimens were sent for examination and the report showed that the cyst was an orthokeratotic odontogenic cyst.

During the operation, using envelope incision, the lower-left-third molar was also extracted and its cyst was enucleated (Figure 31). The pathological report for the lower cyst showed it to be dentigerous. The patient remains under observation (Figure 32).

**Figure 25.** OPG view.

**Figure 26.** CT views.

**Figure 27.** Mucoperiosteal flap preparation.

**Figure 25.** OPG view.

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**Figure 26.** CT views.

**Figure 28.** Tooth extraction.

**Figure 29.** Enucleated cyst and extracted tooth.


**Figure 30.** Intranasal inferior meatal antrostomy and packing of the sinus maxillaris.

**Figure 31.** Extracted lower tooth.

**Figure 29.** Enucleated cyst and extracted tooth.

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**Figure 30.** Intranasal inferior meatal antrostomy and packing of the sinus maxillaris.

```
Figure 32. 5 year postoperative OPG.
```
#### **6.4. Case 4**

A 26-year-old female was referred to our department with severe headache, fatigue, difficulty in nasal breathing, halitosis, and a slowly growing facial deformity on the right site of the face. After radiological assessment (OPG and CT) and clinical examination (Figure 33), it was seen that there was a cyst that almost completely filled the right maxillary sinus and there was slight,

but obvious, facial asymmetry caused by the swelling over the right maxillary region. The mass

was firm and non-tender on palpation and not adherent to the overlying skin. Intra-oral

examination showed expansion of the upper right molar region.

Endodontic treatment was performed for the upper right first and second premolars and for the second molar tooth. It was decided that the first molar roots and third molars would be extracted. All important anatomical points were carefully checked on CT scans.

An operation was performed under general anesthesia, with combined local anesthesia. A trapezoid mucoperiosteal flap was designed and carefully elevated (Figure 34). The teeth were extracted and the cyst was enucleated (Figure 35); and apical resection was performed (Figure 36). An intranasal inferior meatal antrostomy was performed as was packing of the sinus (Figures 37, 38); this was removed 3 days later. Endoscopic assistance was not used because of good visualization. Pathological specimens were sent for examination and report confirmed a radicular cyst (Figure 39).

**Figure 33.** Radiological (OPG and CT) and intraoral clinical views.

that there was a cyst that almost completely filled the right maxillary sinus and there was slight,

but obvious, facial asymmetry caused by the swelling over the right maxillary region. The mass

was firm and non-tender on palpation and not adherent to the overlying skin. Intra-oral

Endodontic treatment was performed for the upper right first and second premolars and for

the second molar tooth. It was decided that the first molar roots and third molars would be

An operation was performed under general anesthesia, with combined local anesthesia. A

trapezoid mucoperiosteal flap was designed and carefully elevated (Figure 34). The teeth were

extracted and the cyst was enucleated (Figure 35); and apical resection was performed (Figure

36). An intranasal inferior meatal antrostomy was performed as was packing of the sinus

(Figures 37, 38); this was removed 3 days later. Endoscopic assistance was not used because

of good visualization. Pathological specimens were sent for examination and report confirmed

a radicular cyst (Figure 39).

extracted. All important anatomical points were carefully checked on CT scans.

examination showed expansion of the upper right molar region.

260 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Figure 34.** Mucoperiosteal elevation and cyst exposure.

**Figure 35.** Cyst enucleation.

**Figure 34.** Mucoperiosteal elevation and cyst exposure.

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**Figure 36.** Apical resection.

**Figure 37.** Intranasal inferior meatal antrostomy and packing of the sinus maxillaris.


**Figure 38.** Closed mucoperiosteal flap and enucleated cyst.

**Figure 36.** Apical resection.

264 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Figure 39.** 5 year postoperative OPG

#### **6.5. Case 5**

A 33-year-old male was referred to our department with difficulty in nasal breathing, halitosis, and a slowly growing facial deformity on the left side of the face. From radiological (OPG and CT) and clinical examinations (Figure 42), it was seen that there was a cyst, which was related to the left maxillary teeth and nasal floor, uplifting the sinus floor, although it did not obliterate the sinus ostium and the sinus mucosa was not infected. This information was important for the decision as to whether to perform an intranasal inferior meatal antrostomy or not. In this case, because the parameters for maxillary sinus ventilation were ideal, we did not perform an antrostomy. Before the operation all teeth on the left site underwent endodontic treatment (Figure 41).

An operation was performed under general anesthesia combined with local anesthesia. A trapezoid mucoperiosteal flap was designed and carefully elevated (Figure 42). The buccal cortex was decorticated using a round bur without damaging the cyst wall (Figure 43). Intracystic liquid was aspirated with a 20-cc syringe (Figure 44). During aspiration, cholesterol crystals were observed clearly in the cyst fluid. After enucleation of cyst (Figure 45), apical resection plus MTA retrograde filling was performed and the mucoperiosteal flap was sutured. Pathological specimens were sent for examination and the report was a radicular cyst.

Endodontic surgery involves a combination of curettage of infected tissue and removal of an infected or damaged root apex. Among the causes of failure in endodontic surgery, the most frequent is the incomplete sealing of all communications between the root canal system and periradicular tissues. Many studies have shown that bacteria that remain in the root canal system have access to the periradicular tissues after resection [26, 27] The main purpose of the root-end filling material is to provide an apical seal that prevents the movement of bacteria from the root canal system into the periapical tissues. Recently, an experimental substance, MTA, was suggested as a potential root-end filling material. In a series of *in vitro* studies, the sealing ability of MTA was evaluated, compared with commonly used root-end-filling materials. It was shown that MTA had significantly less dye and bacterial leakage. [26, 28, 29] Some studies have shown that when the root canal is confined hermetically and an adequate retrograde cavity depth is prepared, then variation in the root-end cutting angle does not necessarily cause any difference in microleakage. [26]

**Figure 40.** Radiological (OPG and CT) examination.

**6.5. Case 5**

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(Figure 41).

A 33-year-old male was referred to our department with difficulty in nasal breathing, halitosis, and a slowly growing facial deformity on the left side of the face. From radiological (OPG and CT) and clinical examinations (Figure 42), it was seen that there was a cyst, which was related to the left maxillary teeth and nasal floor, uplifting the sinus floor, although it did not obliterate the sinus ostium and the sinus mucosa was not infected. This information was important for the decision as to whether to perform an intranasal inferior meatal antrostomy or not. In this case, because the parameters for maxillary sinus ventilation were ideal, we did not perform an antrostomy. Before the operation all teeth on the left site underwent endodontic treatment

An operation was performed under general anesthesia combined with local anesthesia. A trapezoid mucoperiosteal flap was designed and carefully elevated (Figure 42). The buccal cortex was decorticated using a round bur without damaging the cyst wall (Figure 43). Intracystic liquid was aspirated with a 20-cc syringe (Figure 44). During aspiration, cholesterol crystals were observed clearly in the cyst fluid. After enucleation of cyst (Figure 45), apical resection plus MTA retrograde filling was performed and the mucoperiosteal flap was sutured.

Pathological specimens were sent for examination and the report was a radicular cyst.

necessarily cause any difference in microleakage. [26]

Endodontic surgery involves a combination of curettage of infected tissue and removal of an infected or damaged root apex. Among the causes of failure in endodontic surgery, the most frequent is the incomplete sealing of all communications between the root canal system and periradicular tissues. Many studies have shown that bacteria that remain in the root canal system have access to the periradicular tissues after resection [26, 27] The main purpose of the root-end filling material is to provide an apical seal that prevents the movement of bacteria from the root canal system into the periapical tissues. Recently, an experimental substance, MTA, was suggested as a potential root-end filling material. In a series of *in vitro* studies, the sealing ability of MTA was evaluated, compared with commonly used root-end-filling materials. It was shown that MTA had significantly less dye and bacterial leakage. [26, 28, 29] Some studies have shown that when the root canal is confined hermetically and an adequate retrograde cavity depth is prepared, then variation in the root-end cutting angle does not

**Figure 41.** Endodontic treatment of the teeth.

**Figure 42.** Preparation and elevation of the mucoperiosteal flap.

**Figure 43.** Buccal cortex decortication.

**Figure 41.** Endodontic treatment of the teeth.

268 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Figure 42.** Preparation and elevation of the mucoperiosteal flap.

**Figure 44.** Intracystic liquid aspiration with a 20-cc syringe and view of cholesterol crystals.

**Figure 45.** Enucleation of the cyst.
