T ea men o a La ge Maxilla y Cys wi h
Ma supialisa ion, Decomp ession, Su gical Endodon ic
The apy and Enuclea ion
Daniel To es-Laga es, Ph.D., D.D.S.1, Juan J. Segu a-Egea, Ph.D., M.D.,
D.D.S.2, Angela Rod íguez-Caballe o, Ph.D., D.D.S.1, José Mª Llamas-
Ca e as, Ph.D., M.D., D.D.S.3, and José L. Gu ié ez-Pé ez, Ph.D., M.D.,
D.D.S.1
1Depa men o S oma ology, O al Su ge y, School o Den is y, Uni e si y o
Se ille, C/ A icena s/n, 41009-Se ille, Spain.
2Depa men o S oma ology, Endodon ics, School o Den is y, Uni e si y o
Se ille, C/ A icena s/n, 41009-Se ille, Spain.
3Depa men o S oma ology, O hodon ics, School o Den is y, Uni e si y o
Se ille, C/ A icena s/n, 41009-Se ille, Spain.
Running i le: La ge maxilla y cys ea men .
Co esponding au ho :
Juan J. Segu a-Egea
Depa men o S oma ology, School o Den is y, Uni e si y o Se ille
C/ A icena s/n, 41009-Se ille, Spain.
e-mail: segu[email p o ec ed]
Abs ac
T ea men o a la ge maxilla y cys wi h decomp ession du ing 3 mon hs,
ollowed by su gical endodon ic he apy o he a ec ed ee h and cys ec omy is
epo ed. Al hough small cys ic lesions equen ly heal simply wi h non-su gical
endodon ic he apy, la ge lesions may need addi ional ea men . I su gical
enuclea ion o a la ge cys ic lesion is elec ed, o he ee h o s uc u es may be
damaged unnecessa ily. The e o e, a case can be made o i s a emp ing he
mo e conse a i e ea men o decomp ession in o de o diminish he size o
he lesion, ollowed by apicoec omy and cys ec omy.
KEY WORDS: Decomp ession; enuclea ion; adicula cys ; apical pe iodon i is.
In oduc ion
T auma ic inju ies o ee h a e a equen occu ence and usually in ol e he
an e io ee h o young pa ien s. Pulp nec osis is a equen sequel o auma. I
mic obial in ec ion occu s, i will esul in he de elopmen o a pe iapical lesion,
which hen e ol es in o one o he ollowing ypes o ch onic in lamma o y
lesions: g anuloma, pe iapical cys , o sca issue. Pe iapical o adicula cys s
a e in lamma o y jaw cys s o ee h wi h in ec ed and nec o ic pulps. The cys s
a e a di ec sequel o ch onic apical pe iodon i is. Al hough he epo ed
p e alence o cys s among apical pe iodon i is lesions a ies om 6% o 55%,
in es iga ions based on me iculous se ial sec ioning and s ic his opa hologic
c i e ia show ha he ac ual p e alence o he cys s is well below 20%1.
Mos adicula cys s de elop slowly and do no become e y la ge. Pa ien s do
no expe ience pain unless acu e in lamma o y exace ba ion is p esen and he
lesions a e o en de ec ed only du ing ou ine adiog aphic examina ion. I he
cys does become la ge, symp oms including swelling, mild sensi i i y, oo h
mobili y and displacemen may be obse ed. The a ec ed oo h does no
espond o he mal o elec ical pulp es 2.
Cu en endodon ic philosophy in he ea men o ee h wi h la ge pe iapical
lesions includes he ini ial use o nonsu gical oo canal ea men . When his
ea men does no succeed in esol ing he pe i adicula pa hosis, addi ional
op ions mus be conside ed, such as nonsu gical e ea men o pe iapical
su ge y. Howe e , he e a e many adi ional easons o choose su gical
ea men as i s choice. The p esence o a la ge (diame e > 20 mm o c oss-
sec ional a ea > 200 mm2) apical adiolucency is ci ed as a eason o
ecommending su gical emo al o he lesion3. When a longs anding, in ec ed,
nec o ic pulp has esul ed in a la ge apical adiolucency, i may be said o be
e ac o y o con en ional ea men because o he high p obabili y o he
lesion's being a cys 4. Ano he si ua ion in which su gical ea men can be
ecommended is when he canal is supposedly "calci ied" o obs uc ed and
nonnego iable. This is o en assumed o be he case when he canal canno be
isualized adiog aphically, pa icula ly i oo -end su ge y had p e iously been
pe o med. Failu e o a case ha was ea ed wi h a me al ob u a ing ma e ial is
ye ano he scena io in which su ge y is equen ly indica ed.
The no mal su gical ea men s o adicula cys s include o al enuclea ion in
he case o small lesions, ma supialisa ion o decomp ession o la ge cys s, o
a combina ion o he wo echniques. Should su gical in e en ion become
necessa y, he decision poin is whe he o aise a lap and comple ely
enuclea e he lesion o o y “decomp ession” i s 5,6. T ying ma supialisa ion
wi h decomp ession i s , he lesion will p edic ably be much smalle and
p esen less di icul y wi h emo al and less isk o damage o associa ed ee h
and i al s uc u es7.
The ollowing case epo desc ibes he managemen o a pa icula ly la ge
maxilla y cys in ol ing ee h #21, 22, 23, 24, and 25, and con ac ing wi h he
nasal ca i y and he maxilla y sinus, by ma supialisa ion wi h decomp ession,
su gical endodon ic he apy and cys ec omy.
Case epo
A heal hy 15-yea -old Spanish man was e e ed o he Den al Clinic o he
Facul y o Den is y o Se illa (Spain) o ea men o a la ge pe iapical lesion
a ound his le maxilla y cen al inciso , ha was discolou ed and had been
p e iously oo - illed because i e e sible pulpi is ollowing a auma ic inju y,
O hopan omog aphy (Fig. 1) demons a ed la ge pe iapical adiolucency,
app oxima ely 4 cm in he ho izon al plane and 3 cm in he e ical plane,
appa en ly associa ed wi h 21, 22, 23, 24 and, pe haps, 25 ee h. Clinical
examina ion e ealed labial swelling o e he a o emen ioned ee h, and he
a ea was ende o palpa ion and pe cussion. Tee h 22, 23, and 24 did no
espond o he mal and elec ical pulp es s. A p o isional diagnosis o adicula
cys was made.
To be e s udy he adiolucen lesion, aking in o accoun i s p oximi y o he
nasal ca i y and he maxilla y sinus, a compu e ized omog aphy (CT) was
asked (Figs. 2a and 2b). CT e ealed a lesion app oxima ely 4 cm wide in he
an e o-pos e io plane a ec ing he whole igh p emaxilla and con ac ing wi h
he loo o he nose and he maxilla y sinus. Thus, he g ea size o he lesion
could be app aised no only in he mesio-dis al aspec , bu also in he bucco-
lingual one. The swelling, he buccal co ical b eak and he bone expansion
we e ob ious. These ea u es indica ed a benign lesion.
Cys ec omy as i s elec ion ea men a his ime would imply oo canal

ea men and apicoec omy o all a ec ed ee h, possible damage o he loo o
he nose o he maxilla y sinus, as well as he use o gene al anaes hesia.
Discussion was unde aken wi h se e al endodon ic and su gical specialis s,
and ma supialisa ion wi h decomp ession was conside ed as a possible
ea men al e na i e. In consul a ion wi h he pa ien and his pa en s, i was
belie ed ha decomp ession o a pe iod o a leas 12 weeks (depending o he
educ ion o he size lesion) ollowing by oo canal ea men o ee h #22, 23,
and 24, apicoec omy o ee h #21, 22, and 23, and enuclea ion o he esidual
lesion would be he ea men o choice in o de o diminish he isk o inju e o
noble s uc u es du ing he su ge y.
A e in il a ion anaes hesia, a Neumann apezoidal lap was made in be ween
he oo eminences o ee h #11 and 23. Upon en y in o he cys ca i y, he e
was a copious d ainage o he ypical s aw-colou ed luid associa ed wi h cys ic
lesions o in lamma o y o igin, wi hou pu ulen sec e ion (Fig. 3). La age wi h
s e ile saline was accomplished and a biopsy o he cys ic capsule was aken
whose his ological s udy con i med he diagnosis o in lamma o y cys . Then, an
o i ice was made h ough he mucosa and an app oxima ely 2-cm leng h o
#10F adiopaque la ex ubing was inse ed o he dep h o he cys ca i y. One
4-0-gu su u e was placed abo e and below he d ain. Ano he su u e was
placed h ough he d ain i sel as well as h ough mucosa o s abilize i du ing
ini ial healing (Fig. 4). The pa ien was ins uc ed o i iga e h ough he lumen o
he la ex ubing h ee imes a day wi h chlo hexidine 0.12%, consis en wi h a
p o ocol p e iously desc ibed by B ondum and Jensen8.
The pa ien was ecalled a e 3 mon hs when adiog aphic examina ion
e ealed signi ican healing (Fig. 5). Radiog aphs showed ha abecula bone
was o ming and he adiolucen a ea was diminished, as well as he dis ances
be ween he cys and he nasal ca i y and he maxilla y sinus. Howe e , healing
was no comple e. Su gical endodon ic he apy along wi h enuclea ion o he
cys was indica ed.
Endodon ic ea men s o ee h 22 – 24 we e pe o med. B ie ly, ollowing an
adequa e local anaes hesia and isola ion wi h ubbe dam, an endodon ic
access ca i y was es ablished. The oo leng h was es ima ed using an apex
loca o (AFA Apex Finde , Analy ic Technology, O ange Coun y, CA, USA) and
hen con i med wi h a pe iapical adiog aph. A e apical pa ency, he canal ( wo
canals in oo h #24) was cleaned and shaped, d ied and ob u a ed by cold
la e al condensa ion o gu a-pe cha (Den sply Maille e , Ballaigues,
Swi ze land) and seale (AH Plus, Den sply DeT ey, Kons anz, Ge many), and
he access openings o he ee h we e illed wi h acid e ched composi e esins.
A e six days, cys ec omy was pe o med unde local anaes hesia. The buccal
laps we e aised and he cys enuclea ed. A ull his ological s udy o he cys ic
capsule was ca ied ou o exclude he exis ence o ano he umou ype and
he p e ious diagnosis o in lamma o y cys was con i med. The d ain was
emo ed, he mucosal o i ice was su u ed, and apicoec omy o ee h #21, 22,
and 23 was ca ied ou (Figs. 6a, 6b and 7)”.
Healing was une en ul, and one week a e he ope a ion, he su gical si es
showed good healing (Fig. 8). The pa ien was ecalled 1, 3, and 6 mon hs.
Clinical examina ions showed no sensi i i y o pe cussion o palpa ion, and he
so issues we e heal hy a hese examina ions. A e 8 mon hs, he e we e
comple e clinical healing and adiog aphic esolu ion o he maxilla y
adiolucency (Figs. 9 and 10).
Discussion
The maxillo acial egion cons i u es place o a g ea a ie y o cys s and
neoplasias whose iden i ica ion can be e y di icul . The mos impo an o
hese lesions a e maxilla y cys s1. Cys s a e pa hological ca i ies wi h a de ined
wall o connec i e issue and an epi helial ca pe . Cys s a e illed wi h a liquid,
semi liquid o gaseous con en and g ow h cen i ugally and sp eading ou
slowly and in il a i e9. Radicula cys s a e hough o a ise om epi helial cell
es s o Malassez in he pe iodon al ligamen and a e belie ed o p oli e a e as
a esul o pe iapical in lamma ion consecu i e o he in ec ion o he oo canal
sys em, ha ing pa icula ly high incidence in he maxilla y an e io egion,
p esumably as a esul o auma 10.
The e has been a p olonged deba e abou he managemen o la ge cys ic
lesions 11. The ea men op ions o la ge pe iapical lesions may ange om
con en ional nonsu gical oo canal ea men wi h long- e m calcium hyd oxide
he apy o a ious su gical in e en ions. Al hough some endodon is s main ain
ha ue cys s ( hose con aining ca i ies comple ely enclosed by epi helial
lining) can only be success ully ea ed by su gical means12, cu en endodon ic
philosophy in he ea men o ee h wi h la ge pe iapical lesions includes he
ini ial use o nonsu gical oo canal ea men 13. Bu oo canal ea men does
no always succeed in esol ing he pe i adicula pa hosis. Thus, he p e alence
o oo illed ee h wi h ch onic apical pe iodon i is has been ound o be high in
epidemiological s udies ca ied ou in he Spanish popula ion14,15. So, a e oo
canal ea men pa ien s mus be gi en an appoin men a 6 mon hs o a clinical
and adiological e alua ion o he esolu ion o he pe iapical p ocess a e
endodon ic ea men , bu wha happens i he lesion was no o endodon ic
o igin and he pa ien does no e u n, o e en i he pa ien e u ns, 6 mon hs
ha e passed? O in he case ha i was a pe iapical cys , wha happens i i has
no been esol ed sa is ac o ily and he pa ien only e u ns when he symp oms
eappea and/o he si ua ion wo sens? I will e iden ly be necessa y o p o ide
su gical ea men o a lesion ha is much mo e comp omising o adjacen
s uc u es han in i s ini ial s ages11.
The su gical li e a u e clea ly ecommends enuclea ion o he cys because
ma supialisa ion has he isk o lea ing cys ic cells behind ha may become
malignan 16,17. Howe e , we el his was he bes ea men op ion o his
pa ien .
On he o he hand, su geons, in de ence o he su gical al e na i e, a e no
closed o he possible success o pe ec endodon ic ea men , bu hey insis
on he diagnos ic alue o pe iapical su ge y he eby ouching on a so e poin
among endodon is s. Tha is, a pe ec canal ea men , o pe ec e- ea men