Ann Otol 89:1980
TREATMENT OF MAXILLARY CYSTS
GERALD E . MERWIN, M D
GAINESVILLE, FLORIDA
L A W R E N C E R. B O I E S , j R , , MD
ST. PAUL, MINNESOTA
Differing classification systems for cysts of the maxilla have resulted in confusion in the literature regarding these cysts. We feel that
proper evaluation and treatment is essentially the same regardless of the classificatory system employed. The hallmark of proper treatment
of these cysts is meticulous removal of all cyst lining to prevent recurrence. Three case reports are presented and discussed.
INTRODUCTION
Cysts of t h e maxilla a r e relatively r a r e . H o w e v e r ,
Harris a n d Toller h a v e observed t h a t these cysts
may be t h e most c o m m o n benign destructive lesion
of the skeleton.' Cystic lesions of the maxilla are of
particular i m p o r t a n c e to the otolaryngologist d u e to
their proximity to the nasal cavity a n d the maxillary
sinuses. Discussion in t h e literature regarding max­
illary cysts centers p r i m a r i l y on classification a n d
n o m e n c l a t u r e . O u r purpose in this report will not
b e to engage in further discussion of classification
but r a t h e r to recognize cysts of the maxilla as a
surgical entity a n d present a rational a p p r o a c h to
evaluation a n d t r e a t m e n t .
CLASSIFICATION
Disagreement exists in the classification of max­
illary cysts. Systems of classification h a v e been
based on: I) the presumed cell of origin; 2) location;
3) active vs passive cyst g r o w t h ; a n d 4) histology of
the cyst lining.^"" This has resulted in an a r r a y of
terms including follicular cyst, p r i m o r d i a l cyst, ra­
dicular cyst, residual r a d i c u l a r cyst, periodontal
cyst, dentigerous cyst, odontogenic keratocyst,
globumaxillary cyst, nasoalveolar cyst, a n d others.
Based on a review of the literature as well as our
o w n clinical experience, w e suggest t h a t the treat­
ment a p p r o a c h to these cysts, regardless of their
n a m e or classification, is essentially t h e same.
EVALUATION
T h e r e is considerable variation in the clinical
presentation of cysts of the maxilla. Often, the
asymptomatic cyst is noted on routine dental or si­
nus x-rays.* T h e patient m a y present with painless
or painful swelling in t h e region of the p r e m a x i l l a . '
On occasion there is history of dental t r a u m a , ' a b ­
normal occlusion,Or vague complaints of maxillary
sinus or dental p a i n . ' ' "
From the Department of Otolaryngology, University of Minnesota Medical School, Minneapolis, Minnesota; and St. Paul Ramsey Hospital, St. Paul,
Minnesota,
REPRINTS - Gerald E. Merwin, MD, Division of Otolaryngology, College of Medicine, University of Florida, Gainesville, FL 32610.
225
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THOMAS TILSNER, M D
TUCSON, ARIZONA
D O N A L D S. SHREWSBURY, M D
MINNEAPOLIS, MINNESOTA
Initial evaluation of the p a t i e n t must include a
t h o r o u g h oral a n d nasal e x a m i n a t i o n . Swelling into
t h e floor of t h e nose m a y alter t h e r e q u i r e d surgical
a p p r o a c h . Radiologic evaluation of the cyst relative
to t h e nose a n d sinuses is essential for t r e a t m e n t
p l a n n i n g . Therefore, sinus views as well as a
Panorex® study'" should b e o b t a i n e d .
In those instances w h e r e p r e o p e r a t i v e sinus x-rays
reveal m i n i m a l b o n y separation b e t w e e n t h e cyst
a n d t h e a n t r u m or nasal cavity, marsupialization
m a y b e considered as an alternative to complete
cyst r e m o v a l . * " This m a y avoid i n a d v e r t e n t entry
into t h e nose or a n t r u m w i t h subsequent oral-antral
or oral-nasal fistula formation. If t h e r e is evidence
of maxillary sinus disease related to t h e cyst, the
creation of a n a s o a n t r a l w i n d o w m a y be indicated
at t h e t i m e of surgery. T h e location a n d dimensions
of t h e cyst must be w e l l - d e t e r m i n e d prior to surgery
in order to insure t h a t incisions are placed to pro­
vide m a x i m u m exposure.
M a l i g n a n t transformation of an odontogenic cyst
is exceedingly r a r e . ' ' ^ ' ^ E r a s m i e a n d Haverling
reported both routine x-ray a n d t o m o g r a p h i c find­
ings w h i c h m a y b e used to differentiate benign from
m a l i g n a n t cysts. M a l i g n a n t lesions are associated
w i t h well-defined areas of irregular b o n e destruc­
tion.'" In cases w h e r e m a l i g n a n c y is suspected, b o n e
scan or needle aspiration of the cyst for cytology
m a y prove u s e f u l . ' * " If t h e r e is a high index of
suspicion for m a l i g n a n t t r a n s f o r m a t i o n , a m o r e ag­
gressive t r e a t m e n t a p p r o a c h m a y be indicated. Cer­
tainly, all cyst lining removed at surgery should be
carefully examined histologically.
TREATMENT
T r e a t m e n t p l a n n i n g for maxillary cysts must be
p r i m a r i l y directed t o w a r d c o m p l e t e eradication of
disease to prevent r e c u r r e n c e . Recurrence rates
h a v e been reported in t h e r a n g e of 2 5 - 6 0 % ' * "
226
necessitating repeated surgical procedures with
their a t t e n d a n t morbidity a n d expense to the pa­
tient. T h e p r i m a r y factor leading to recurrence of
maxillary cysts is failure to completely remove t h e
cyst lining.' As pointed out by Bramley, com­
plete removal is often difficult because; 1) the cyst
lining is sometimes very thin a n d difficult to iden­
tify; 2) residual epithelial microcysts m a y exist be­
tween the gingiva and the m a i n cyst wall; 3) satel­
lite cysts m a y be present adjacent to the m a i n cyst;
and 4) budding-off of the basal layers of the cyst lin­
ing m a y occur. F u r t h e r m o r e , cyst lining m a y be con­
tiguous with overlying alveolar ridge m u c o s a . "
W i d e surgical exposure is of utmost i m p o r t a n c e
in obtaining complete removal of the cyst lining.
This m a y be accomplished by a s t a n d a r d Caldwell-
L u c a p p r o a c h or by the use of a gingivomucoperi-
osteal flap as described by R a m o n et a l . " This flap
is based superiorly and vertical incisions are carried
d o w n to the interdental papillae. A periosteal ele­
vator lifts the flap from the alveolar ridge. In­
terdental papillae are sectioned as they are en­
countered. A continuous transverse alveolar ridge
incision is used in edentulous patients. W e recom­
m e n d this flap because it provides a d e q u a t e ex­
posure while it avoids disadvantages of the gingivo-
labial sulcus approach including: 1) lack of bony
support of the suture line resulting in depression
and adhesion of the scar to the underlying cavity; 2)
reduction in the depth of the gingivobuccal sulcus
such that dentures may not fit properly a n d may
cause pressure and pain along the suture line; a n d
3) injury to the sensory nerve supply of the gingivae,
which may cause pain or anesthesia. W i d e bony re­
moval over the anterior face of the cyst m a y be car­
ried out with chisel, b o n e forceps, or large c u t t i n g
burrs. If infection is encountered, aspiration
samples should be sent for G r a m staining a n d both
aerobic and anaerobic c u l t u r e . A b r o a d spectrum
antibiotic may be started p e n d i n g the results of an­
tibiotic sensitivity testing.
All grossly evident cyst lining is first removed
with periosteal elevators. Problem areas, such as the
space behind tooth roots projecting into t h e cavity,
must be carefully evaluated a n d cleaned. T h e cyst
m a y contain an u n e r u p t e d tooth, w h i c h , of course,
is removed. In order to insure t h a t all lining has
been eradicated, the cyst cavity m a y be examined
using the operating microscope. Suspicious areas
may be cleaned and polished using polishing b u r r s .
If the cyst lining extends close to the margin of the
maxillary alveolus, the overlying alveolar ridge
mucosa should be removed along with the cyst lin­
ing.
After the cyst lining has been completely
eradicated, the resultant cavity is allowed to fill
with blood a n d the surgical incision is closed. If
oozing is significant, gauze packing or a Penrose
drain m a y be placed t e m p o r a r i l y . T h e defect will
ultimately be filled in by n e w bone formation.
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MERWINETAL
Fig. 1. (Case 1) The gingivomucoperiosteal flap for
removal of maxillary cyst.
In view of the relatively high recurrence rates of
maxillary cysts, a d e q u a t e postoperative follow-up is
essential. Annual x-ray examination for a period of
five to ten years has been suggested.*
CASE R E P O R T S
Case 1. The patient is a 32-year-old Negro male who presented
with a three-year history of intermittent, slightly tender swelling
of the upper lip which had been persistent for the past three
months. There was associated hypoesthesia over the upper lip and
mild pain in the surrounding maxillary teeth. Examination
revealed a soft tissue swelling in the upper gingivobuccal sulcus
just to the right of the midline with a fluctuant area in the adja­
cent hard palate. Intranasal examination showed a slight swelling
in the floor of the right vestibule, and the right ala appeared to be
slightly elevated by the mass. Panorex examination demonstrated
a cystic mass in the maxilla. Surgical approach via a gingivoperi-
osteal flap (Fig. I) revealed a cystic mass protruding through a
dehiscence in the anterior face of the maxilla just to the right of
the midline. The cyst was filled with a brownish fluid which was
sterile on culture. Complete removal of the cyst lining, which was
very thin and fragile, revealed a small bony dehiscence in the
hard palate, but the overlying hard palate mucosa was intact.
The surgical incision was closed without packing or drains.
Histologic examination of the cyst lining showed dense fibrous
connective tissue containing respiratory epithelium with focal
areas of cholesterol clefts. Pathologic diagnosis was nasoalveolar
cyst.
Case 2. The patient is a 21-year-old native American male who
presented with a painless mass in the right cheek of approximately
five years duration. He related this mass to multiple episodes of
trauma to the area. The mass was firm in consistency and was
situated over the anterior wall of the maxillary sinus, extending
medially to the lateral wall of the nose, superiorly to the infraor­
bital rim, and inferiorly protruding into the gingivobuccal sulcus.
Sinus roentgenograms revealed an unerupted tooth in the middle
of the mass. Due to the size of the cyst a gingivolabial incision was
chosen for the surgical approach. The cystic lesion was filled with
brownish fluid under pressure. The anterior wall of the antrum
was depressed but not eroded by the cyst. The lining of the cyst
was felt to arise from the crown of an unerupted tooth in the
center of the cyst (Fig. 2). All lining, as well as the unerupted
tooth, was removed. The cyst cavity was packed with iodoform
gauze, which was removed gradually over three days. Histologic
examination of the cyst lining revealed squamous epithelium
overlying a base of fibrous tissue. One area showed cholesterol
clefts. Pathologic diagnosis was dentigerous cyst.
 TREATMENT
Fig. 2. (Case 2) Unerupted tooth in the center of the
maxillary cyst.
Case 3. The patient is a 21-year-old Caucasian female who was
found to have bilateral maxillary cysts on an orthopantomogram
taken during routine dental evaluation. She had a past history of
severe closed head trauma in an auto accident, and the referring
dentist felt that these cysts were traumatic in nature. The patient
complained of pain on the right side of the mouth when eating,
and oral examination revealed a slightly tender, soft mass over the
right hard palate. Nasal examination and sinus roentgenograms
showed no intrinsic parthology. Orthopantomogram showed a
large right maxillary cyst and a smaller left maxillary cyst.
The cyst on the right side was approached via a Caldwell-Luc
incision. The anterior face of the maxilla was eroded by the cyst,
which contained a milky, whitish fluid. The cyst essentially
replaced the right antrum and eroded through the bony inferior
turbinate medially. It extended well posteriorly on the hard
palate and created a small bony dehiscence, but the overlying
palate mucosa was intact. After all of the cyst lining was carefully
removed, a nasoantral window was created by incising a flap of
mucosa over the inferior turbinate. The wound was closed
without packing or drains.
REFERENCES
1. Harris M, Toller P. The pathogenesis of dental cysts. Br
Med Bull 1975; 31:159-63.
2. Eversole LR, Sabes WR, Rovin S. Aggressive growth and
neoplastic potential of odontogenic cvsts. Cancer 1975;
35:270-82,
3. Dayal VS, Jones J, Noyek AM, Management of odon­
togenic maxillarv sinus disease. Otolaryngol Clin North Am 1976;
9:213-22,
4. Summers GW. Jaw cvsts: diagnosis and treatment. Head
Neck Surg 1979; 1:243-56.
5. Bernstein G. The residual radicular dental cyst, a case
report and discussion, NY State Dent 1976; 42:548-55.
6. Galil KA, Dentigerous cvst of the maxillarv sinus. J Oral
Med 1977; 32:56-8.
7. Samanta A, Bilateral radicular cvsts. Oral Surg 1976;
41:542-3.
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OF MAXILLARY CYSTS 227
The cyst on the left side was much smaller and was approached
via a gingivomucoperiosteal flap. Again, the anterior face of the
maxilla was dehiscent over the flap. The cyst contained the root of
a tooth which had apparently been avulsed at the time of the pa­
tient's head trauma. AH cyst lining, as well as the tooth root, was
removed and the surgical incision was closed.
The histologic appearance of the lining of both cysts was iden­
tical. Squamous epithelium was seen overlying a fibrous stroma
containing inflammatory cells. Pathologic diagnosis was nasoal-
veolar cyst on the right and periapical cyst on the left.
DISCUSSION
In these cases w e find v a r y i n g p r e s e n t a t i o n s of
b o n y m a x i l l a r y cysts. Roentgenologic e v a l u a t i o n in
e a c h case w a s diagnostic for m a x i l l a r y cyst w i t h o u t
e v i d e n c e of m a l i g n a n c y . T h e size a n d location of
t h e lesion d i c t a t e d t h e t y p e a n d p l a c e m e n t of t h e in­
cision in o r d e r to p r o v i d e sufficient exposure for
visualization w i t h i n t h e cavity to insure c o m p l e t e
r e m o v a l of cyst lining. W e p r o c e e d e d w i t h a na­
s o a n t r a l w i n d o w in one case d u e to t h e e n c r o a c h ­
m e n t of t h e cyst on t h e n a t u r a l ostium of t h e max­
illary sinus w h e n this w a s n o t e d at t h e t i m e of
o p e r a t i o n . P a t h o l o g i c diagnoses in these cases
revealed t h r e e different types of cysts; t w o different
types w e r e found in t h e s a m e p a t i e n t . Although t h e
classification of these cysts v a r i e d , t h e e v a l u a t i v e
p r o c e d u r e s a n d surgical t r e a t m e n t w e r e t h e s a m e in
t r e a t i n g all of these p a t i e n t s .
CONCLUSION
W e suggest t h a t cysts of t h e maxilla, regardless of
t h e i r n a m e or classification, r e q u i r e t h e s a m e
surgical t r e a t m e n t . W e h a v e discussed p r e o p e r a t i v e
e v a l u a t i o n , w h i c h should i n c l u d e a t h o r o u g h oral
a n d nasal e x a m i n a t i o n as well as Panorex a n d sinus
r o e n t g e n o g r a m s . Periodic p o s t o p e r a t i v e follow-up
x-rays a r e also i m p o r t a n t . T h e h a l l m a r k of a d e ­
q u a t e surgical t h e r a p y for b o n y cysts of t h e maxilla
is meticulous r e m o v a l of all cyst lining to p r e v e n t
recurrence.
8. Sudderth ME. Calcifying odontogenic cyst (Gorlin's cyst)
of the maxillary sinus. Laryngoscope 1976; 86:1845-8.
9. Khan MY, Kwee H, Schneider LC, et al. Adenomatoid
odontogenic tumor resembling a globulomaxillary cyst: light and
electron microscope studies, J Oral Surg 1977; 35:739-42,
10. Eisenbud L, Kameros J, Blud B, et al. The importance of
panographic and dental evaluation for lesions of the
antrum.Laryngoscope 1976; 86:1004-7,
11. Litwiller OB. Globulomaxillary cyst treated by mar­
supialization. Dent Radiogr Photogr 1975; 48:42-5.
12. Tsaknis PJ, Carpenter WM, Shade NL. Odontogenic
adenomatoid tumor: report of case and review of the literature. J
Oral Surg 1977; 35:146-9.
13. Marteinelli C, Melhado RM, Callestini EA. Squamous cell
carcinoma in a residual mandibular cyst. Oral Surg 1977;
44:274-8.
228 MERWINETAL

14. Erasmie U, Haverling M. Radiologic differentiation be­
tween cysts and malignant tumors of the maxilla. Acta Radiol
[Diagn] (Stockh) 1976; 17:538-44.
15. Lurie AG, Puri S, James RB, et al. Radionuclide bone im­
aging in the surgical treatment planning of odontogenic
keratocysts. Oral Surg 1976; 43:726-30.
16. Bromley P. The odontogenic keratocyst — an approach to
treatment. Int J Oral Surg 1974; 3:337-41.
17. Brannon RB. The odontogenic keratocyst. Oral Surg 1977;
43:233-55.
18. Ramon Y , Oberman M, Freedman A, et al. The maxillary
sinus: a surgical approach via a gingivomucoperiosteal flap. Arch
Otolaryngol 1976; 102:637-9.

CORRECTION
KERATOACANTHOMA OF THE HEAD AND NECK

R I C H A R D E. GOODWIN, MD GEORGE H . FISHER, MD

NEW YORK, NEW YORK CORPUS CHRISTI, TEXAS

Vol. 89, Jan-Feb, 1980, pages 72-74

D u e to problems t h a t developed after completion of editing a n d in the final p a s t e - u p , t h e following t h r e e

p a r a g r a p h s w e r e inadvertently o m i t t e d . Corrected reprints of this article m a y b e o b t a i n e d b y w r i t i n g to
Richard E . G o o d w i n , M D , 235 East 67th Street, N e w York, NY 10021, or to t h e Annak of Otology,
Rhinology it Laryngology, 4949 Forest Park Blvd., St. Louis, M O 63108.

T h i r d , although k e r a t o a c a n t h o m a does h a v e a F o u r t h , because of t h e location of these lesions on

propensity for spontaneous regression, m a n y do not t h e exposed areas of the h e a d a n d neck, few patients
b e h a v e in this m a n n e r . Reports exist of m a l i g n a n t are content to w a i t for possible regression. T h e cos­
transformation in previously diagnosed benign le­ metic defect a n d concern a b o u t underlying malig­
sions. Jesunas' reported t w o cases of s q u a m o u s cell n a n c y are causes for the patient's insistence on
c a r c i n o m a in which the histologic diagnosis of ker­ definitive t r e a t m e n t offered only by excision.
a t o a c a n t h o m a was m a d e . H e r e c o m m e n d e d conser­
Finally, early surgical excision is simple, effi­
vative t r e a t m e n t be avoided. Also, others h a v e re­
cient, a n d results in a m o r e acceptable cosmetic
ported benign lesions which b e c a m e invasive a n d
result t h a n t h a t of spontaneous resolution, which
acted clinically as malignant lesions w h i c h metasta­
frequently leaves t h e p a t i e n t w i t h a depressed,
s i z e d . ' " Rook a n d C h a m p i o n ' " stated "as one's ex­
d e p i g m e n t e d scar in t h e area.
perience with these lesions increases, so does one's
confidence in accepted histological criteria of ma­
lignancy decline."

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