Huge radicular cyst of the maxilla: Some clinicopathological considerations

Otolaryngology–Head and Neck Surgery (2010) 143, 853-854

LETTER TO THE EDITOR Huge radicular cyst of the maxilla: Some clinicopathological considerations

Poramate Pitak-Arnnop, MSc, DDS University Hospital of Leipzig Leipzig, Germany University Paris 5 (René Descartes) Paris, France Kittipong Dhanuthai, MSc, DDS University Hospital of Leipzig Leipzig, Germany Chulalongkorn University Bangkok, Thailand Alexander Hemprich, MD, DMD, PhD Niels Christian Pausch, MD, DMD, PhD University Hospital of Leipzig Leipzig, Germany

Although we would like to congratulate Lee and Byun on their report regarding a gigantic radicular cyst of the maxilla,1 there are some areas for discussion that can be listed as follows. 1) Differential diagnosis of a maxillary lesion in the toothbearing area includes radicular cyst, odontogenic keratocyst (OKC), ameloblastoma, adenomatoid odontogenic tumor, ameloblastic fibroma, myxoma, and glandular odontogenic cyst.2 The radicular cyst results from proliferation of epithelium remnants at the apex of a necrotic tooth in response to signals such as inflammatory mediators, proinflammatory cytokines, and growth factors released by innate and adaptive immune cells during apical periodontitis.2,3 Hence, the negative response to the vitality test and the loss/discontinuity of the radiographic lamina dura of tooth/teeth within the lesion serve as a diagnostic clue.2,3 It is noteworthy that many OKCs and ameloblastomas present as the large cyst-like lesion of the jaws. Our previous study showed that six of 120 OKCs (or 5%) with secondary infection were diagnosed as a radicular cyst by clinical, radiographic, and histologic means. The definite diagnosis was established after their recurrences. Long-term follow-up and repeated histopathologic examinations are therefore essential.4 2) Lee and Byun1 did not mention the vitality of the neighboring teeth and whether nonsurgical dental root canal therapy (NDRCT) was given for the necrotic tooth/teeth. The radicular cyst is not a tumor. Treating only the cyst never cures the disease unless root canal infection is eliminated.3 Some authors suggested that NDRCT alone can be tried in most cases as the lesions might regress or even completely heal after NDRCT by the mechanism of apoptosis.3 Nevertheless, the type of the lesion and its radiographic size are associated with the disease prognosis. Large radicular cysts usually require an enucleation to remove the cyst’s lining epithelium and cholesterol crystals that prevent or delay periapical wound healing.3,5 3) Decompression and marsupialization reduce the cystic size, and make an incisional biopsy and subsequent complete removal of the cyst feasible. However, these techniques necessitate a longer treatment, multistage procedures, and patient cooperation. Furthermore, the biopsy specimen may be unrepresentative of the real diagnosis.2,4 In keeping with the law of gravity, it is reasonable to surmise that the content from maxillary cysts can be drained much more easily into the oral cavity. An oral vestibular approach is therefore more preferable than a nasal approach. The treatment algorithm for cyst-like lesions in the jawbone was described in our previous publications.2,4

References 1. Lee JY, Byun JY. Huge radicular cyst. Otolaryngol Head Neck Surg 2010;143:704 –5. 2. Chaine A, Pitak-Arnnop P, Dhanuthai K, et al. An asymptomatic radiolucent lesion of the maxilla. Clear cell odontogenic carcinoma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:452–7. 3. Lin LM, Ricucci D, Lin J, et al. Nonsurgical root canal therapy of large cyst-like inflammatory periapical lesions and inflammatory apical cysts. J Endod 2009;35:607–15. 4. Pitak-Arnnop P, Chaine A, Oprean N, et al. Management of odontogenic keratocysts of the jaws: a ten-year experience with 120 consecutive lesions. J Craniomaxillofac Surg 2010;38:358 – 64. 5. Carrillo C, Peñarrocha M, Bagán JV, et al. Relationship between histological diagnosis and evolution of 70 periapical lesions at 12 months, treated by periapical surgery. J Oral Maxillofac Surg 2008;66:1606 –9.

doi:10.1016/j.otohns.2010.09.025

Response to: Huge radicular cyst of the maxilla: Some clinicopathological considerations, from Pitak-Arnnop et al We thank Dr. Poramate Pitak-Arnnop and his colleagues for their comments on our recently published article, titled “Huge radicular cyst,” and for sharing their experiences on tooth-bearing maxillary lesions. First, we agree with their comment that long-term follow-up is mandatory.1 Although a radicular cyst is strongly suggested based on the clinical, radiologic, and histologic evidence, the definite diagnosis cannot be established unless the entire cyst is removed. However, as we described in the article, complete enucleation of the lesion was almost impossible because of the large size of the cyst and its involvement with the tooth roots. In addition, we did not consider an additional histopathologic examination because the lesion was reported to be a radicular cyst initially, and the postoperative endoscopic and radiologic examinations did not show any evidence of recurrence or a tumor. The

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