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Clinical and Radiological Characteristics in Patients with Postoperative Maxillary Cyst: A Retrospective Study
J Oral Med Pain 2023;48:81-86
Published online September 30, 2023;  https://doi.org/10.14476/jomp.2023.48.3.81
© 2023 Korean Academy of Orofacial Pain and Oral Medicine

Hyoung-Cheol Kim1│Suk-Ja Yoon2│Yeong-Gwan Im3│Jae-Seo Lee2

1Dental Science Research Institute, School of Dentistry, Chonnam National University, Gwangju, Korea
2Department of Oral and Maxillofacial Radiology, Dental Science Research Institute, School of Dentistry, Chonnam National University, Gwangju, Korea
3Department of Oral Medicine, Dental Science Research Institute, School of Dentistry, Chonnam National University, Gwangju, Korea
Correspondence to: Jae-Seo Lee
Department of Oral and Maxillofacial Radiology, Dental Science Research Institute, School of Dentistry, Chonnam National University, 77 Yongbong-ro, Buk-gu, Gwangju 61186, Korea
E-mail: jsyi16@jnu.ac.kr
https://orcid.org/0000-0001-8059-0378
Received June 3, 2023; Revised July 27, 2023; Accepted July 28, 2023.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Purpose: To evaluate the clinical and radiologic findings of the postoperative maxillary cysts (POMCs) and investigate the relationship between lesion size and clinical symptoms depending on the time elapsed after radical maxillary sinus surgery.
Methods: A total of 29 patients who were diagnosed with POMCs at Chonnam National University Dental Hospital were selected. Clinical and radiologic findings were investigated. POMC cases were divided into two groups: those with <24 years between maxillary sinus surgery and POMC diagnosis and those with >24 years. The chi-square test was used to compare the differences between the two groups.
Results: The average period from surgery to POMC detection was 24.32 years; however, the period could not be confirmed in four patients. The average patient age was 52.75 years, and 12 (41.3%) patients were in their 50s. POMC-related clinical symptoms were as follows: buccal pain and swelling, dull pain, toothache, abscess, sensory abnormality, and asymptomatic. Twenty (69.0%) cases showed unilocular radiolucency and 9 (31.0%) revealed multilocular radiolucency. Seven cases (35.0%) were misdiagnosed as odontogenic lesions, resulting in the delayed treatment of POMCs. No statistical significance was found between the two groups with respect to symptoms, expansion to the surrounding area, presence of secondary cysts, and mesiodistal length of cyst on cone-beam computed tomography (CBCT) images. However, the buccopalatal length of the cyst on CBCT images was significantly different between the two groups.
Conclusions: The buccopalatal length of POMCs observed on CBCT images was related to the time elapsed since surgery. The lack of awareness of POMCs may lead to misdiagnosis as an odontogenic infection and delayed treatment. Therefore, dentists must recognize the clinical and radiologic features of POMCs to differentiate it from dental infections.
Keywords : Cysts; Dental; Maxillary sinus; Radiography
INTRODUCTION

Postoperative maxillary cyst (POMC) was first reported in 1927 by Kubo in Japan [1]. POMC occurs years or decades following Caldwell–Luc operation, orthognathic surgery, or maxillary sinus augmentation and is caused by epithelial residues at the surgical site [2-8]. POMCs can cause swelling or perforation of the maxillary sinus wall as it gradually grows over several years.

Although often asymptomatic, various symptoms such as pain in the teeth and alveolar bone or gingival fistulas may appear with increasing POMC size [9,10]. The lack of awareness of POMCs may lead to misdiagnosis as an odontogenic infection and delayed treatment. The average latency time was 4-22 years [11]. Owing to the long latency time, whether the clinical and radiologic features of POMCs may change over time need to be compared. To the best of our knowledge, no studies have compared POMC features across periods. Therefore, this study aimed to provide dentists with information on clinical and radiographic findings of POMC and evaluate the size and symptom difference in lesions according to the time elapsed from radical maxillary sinus surgery to POMC detection.

MATERIALS AND METHODS

This study was conducted on 29 patients diagnosed with POMCs (excluding patients with incomplete electronic medical records) at Chonnam National University Dental Hospital between January 2009 and December 2017. This study was approved by the Institutional Review Committee of Chonnam National University Dental Hospital (IRB no. CNUDH-2019-001).

Patients with a previous history of maxillary sinus surgery and histopathologically confirmed diagnosis of POMCs postoperatively were included. Patients who had no previous history of maxillary sinus surgery, had an incomplete clinical and radiographic evaluation, and had clinical and/ or radiographic evidence of any tumor or pseudocyst in the maxillary sinus were excluded.

The study evaluated age, sex, clinical symptoms, surgical history, and period from radical maxillary sinus surgery to POMC diagnosis using electronic medical records. Radiological characteristics by panoramic radiographs and dental cone-beam computed tomography (CBCT) were also assessed.

Clinical and radiologic findings were investigated according to the elapsed period. The average time of latency for POMCs after the first surgery was 24 (min, 6; max, 40) years. Patients were divided into those who underwent maxillary sinus surgery <24 years ago and those >24 years ago. Four patients were excluded because of missing data on the postoperative period. Twenty-five patients with POMCs were compared using the chi-square test. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 23.0 (IBM Co.), and p<0.05 was considered statistically significant.

RESULTS

The clinical characteristics of the patients diagnosed with POMCs are summarized according to age, sex, location, symptoms, and period until onset after surgery (Table 1). The study included 13 men and 16 women. The average patient age was 52.75 years, and 12 (41.4%) patients were in their 50s.

The average period from surgery to POMC detection was 24.32 years; however, the period could not be confirmed in four patients. The lesion was present on the right side in 17 (58.6%) patients, left side in 7 (24.1%), and both sides in 2 (6.9%). The main symptoms were buccal pain in 17 (58.6%) patients, swelling in 12 (41.4%), pyorrhea in 5 (17.2%), and dullness and toothache in 2 (6.9%). The lesions were found incidentally in 4 (13.8%) patients without specific clinical symptoms.

The radiologic characteristics were recorded according to the lesion location, shape, and size (Table 2). Moreover, 17 (58.6%) patients had lesions on the right side, 7 (24.1%) had them on the left, and 2 (6.9%) had them on both sides. The lesions were categorized as unilocular and multilocular radiolucencies on panoramic radiographs (Fig. 1, 2). Multilocular radiolucencies were observed in 9 (31.0%) patients.

As regards the lesion size, the most extended lengths measured on the buccal–palatal and mesiodistal (MD) sides on the axial plane of the CBCT were recorded (Table 2, Fig. 3). The buccopalatal (BP) length of the lesion was <15 mm in 8 (27.6%) patients, 15-30 mm in 14 (48.3%), and >30 mm in 7 (24.1%). No lesions had an MD length of <15 mm; moreover, 17 (58.6%) lesions measured 15-30 mm, and 12 (41.4%) measured >30 mm (Tables 2, 3). The extent of the lesion was evaluated using CBCT images, and the relationship with the zygomatic bone, ethmoid bone, orbit, and teeth was observed. Moreover, 8 (27.6%) patients had a zygomatic extension, with no ethmoid or orbital extension; however, 20 (69.0%) had tooth involvement. Secondary cysts (Fig. 4) adjacent to the lesion were found in 4 (13.8%) patients.

The patients were divided into those who underwent maxillary sinus surgery <24 years ago and >24 years ago. The study investigated the relationship between the two groups based on clinical and radiologic findings (Table 3). No statistically significant difference was found between the two groups with respect to symptoms, expansion to the surrounding area, and secondary cyst (p-value>0.05, chi-square test). However, the BP lengths of the cyst on CBCT images were significantly different between the two groups (p<0.05).

DISCUSSION

POMC, a late complication, occurs after radical maxillary sinus surgery and is caused by residual mucosal epithelium during surgery [12]. Rarely reported in West countries, POMC is more prevalent in Asia, particularly in Japan [12,13]. The higher incidence in Japan could be attributed to the source of infection and facial skeletal growth [13]. Pain and swelling are the main clinical symptoms of POMCs [14]. In this study, various symptoms were identified, such as toothache, abnormal sensation on the face, and pus discharge in the gingiva. POMC is also found incidentally on radiographs in asymptomatic cases.

As the lesion grows, the sinus wall may become thin, expand, and disappear, and the cyst may invade adjacent areas. Rarely, POMCs affect the orbit [9,15]. Previous studies have shown secondary or multiple cysts, which were isolated by bony septation on CT [16,17]. In this study, secondary cysts were more easily identified on CBCT images than on panoramic radiographs. Therefore, CBCT rather than panoramic radiography is needed to evaluate the POMC size, its relationship with adjacent structures, and related secondary cysts. A study [18] also showed that CT was superior to panoramic radiography and Waters views for POMC diagnosis. In addition, POMC boundaries were clearly observed on magnetic resonance imaging [14].

POMC is more common in women than in men [11]. In this study, POMCs developed in 13 men and 16 women, with a higher predilection for women. Medical history revealed that 29 cases had a history of sinus operation for maxillary sinusitis, and one patient had a zygomaticomaxillary complex fracture. Dental CBCT images showed 8 (27.6%) lesions that laterally extended to the zygomatic bone and 20 (69.0%) that inferiorly extended between the roots of teeth. Seven cases (35.0%) involving the root were mistaken for odontogenic lesions, such as apical cysts or apical abscesses, resulting in the persistence of the clinical symptoms during the treatment of the tooth alone and delayed treatment of the posterior maxillary cyst. In this study, the size of POMCs in the axial view showed a more significant difference in BP length than in MD length based on the period (24 years) after maxillary sinus surgery.

POMCs should be differentiated from apical cysts in the posterior region, retention pseudocysts in the maxillary sinus, and chronic maxillary sinusitis [2,13]. The treatment of POMCs includes Caldwell–Luc operation, marsupialization, and endoscopic surgery [14]. In this study, POMC surgery was performed using the Caldwell–Luc procedure. PMCs were found 10-40 years after maxillary sinus surgery. POMC recurrence was related to the presence of multiple cysts and extensions outside the sinus wall [17,19].

This study has some limitations. All presented data were collected retrospectively, and some clinical information may be missing. Systemic clinical information was not compared, and postoperative recurrence rates have not been studied.

In conclusion, POMCs may emerge several years after radical maxillary sinus surgery, with an average detection period of 24.32 years. The cyst size, particularly the BP length observed on CBCT images, appears to be significantly related to the time elapsed since surgery, highlighting the importance of long-term monitoring for potential POMC development. Dentists should be aware of the clinical and radiologic features of POMCs and consider the possibility of POMCs in addition to odontogenic infection in patients with a history of maxillary sinus surgery when pain or swelling occurs in the maxillary teeth.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

DATA AVAILABILITY STATEMENT

The datasets used in this study are available from the corresponding author upon reasonable request.

FUNDING

None.

AUTHOR CONTRIBUTIONS

Conceptualization: HCK, JSL. Data curation: HCK. Methodology: HCK, SJY, YGI. Project administration: JSL. Visualization: HCK, SJY, YGI. Writing original draft: HCK, JSL. Writing review & editing: JSL.

Figures
Fig. 1. Panoramic radiograph shows a well-defined unilocular radiolucency (white arrow) in the left maxillary sinus (patient 24).
Fig. 2. Panoramic radiograph shows a well-defined multilocular radiolucency (white arrow) in the right maxillary sinus (patient 18).
Fig. 3. Axial CBCT image shows an expansive unilocular radiolucency in the right maxillary sinus (patient 29). CBCT, cone-beam computed tomography.
Fig. 4. (A) Panoramic view showing a well-defined secondary cyst (white arrow) above the right POMC (patient 16). (B, C) Coronal and axial CBCT images of the location of the secondary cyst (white arrow), which was isolated from the right POMC (patient 16). POMC, postoperative maxillary cyst; CBCT, cone-beam computed tomography.
Tables

Summary of patient clinical features

Patient Age/sex Location Symptoms Period after operation (y)
1 56/M R None 40
2 60/M L Pain, swelling, and toothache 25
3 55/F L Pain, swelling, and toothache 38
4 51/M R Swelling and dullness 25
5 45/M L Pain and swelling 15
6 55/M L Pain 25
7 40/M L None 10
8 48/M R Pain and pus discharge 25
9 37/F L Pain and abnormal sensation 10
10 44/M L None Unknown
11 50/F L Swelling 15
12 78/F R Pain Unknown
13 54/F R Pus discharge, pain, and dullness 10
14 47/F R Abnormal sensation 22
15 53/F R Swelling 20
16 44/F R Pain and swelling 25
17 66/F R Dullness and pain 23
18 53/F R Pain 6
19 49/F RL Pain 12
20 57/M RL Pain and swelling 20
21 62/F R Pain, pus discharge, and swelling 40
22 62/F R Pus discharge 30
23 62/F R None 40
24 58/F L Pus discharge and pain 34
25 53/M R None Unknown
26 64/M R Pain and swelling Unknown
27 48/M R Pain and swelling 35
28 56/F L Pain 30
29 48/M R Pain and swelling 33

M, male; F, female; R, right; L, left.

Summary of patient radiographic features

Patient Side Shape of radiolucency Length (mm) Extension to adjacent structures Secondary cyst
BP MD Zygoma Ethmoid Orbit Tooth
1 R Unilocular 19.97 40.51 +
2 L Unilocular 22.17 34.10 +
3 L Unilocular 35.39 40.65 + +
4 R Multilocular 32.66 36.84 + +
5 L Unilocular 28.45 36.51 + +
6 L Unilocular 25.58 26.42 +
7 L Unilocular 43.72 44.30 + +
8 R Unilocular 24.20 25.38 +
9 L Unilocular 7.32 25.50 +
10 L Unilocular 7.40 15.34 +
11 L Multilocular 10.82 16.61
12 R Unilocular 8.32 17.27 +
13 R Unilocular 9.43 20.12
14 R Multilocular 12.34 15.33
15 R Multilocular 30.78 30.69 + +
16 R Unilocular 14.17 21.25 + + +
17 R Multilocular 12.67 22.14 +
18 R Multilocular 28.21 50.19 +
19 RL Multilocular 15.67 22.20 +
20 RL Multilocular 26.94 42.65 +
21 R Unilocular 15.57 28.30 +
22 R Unilocular 21.78 35.22 + +
23 R Unilocular 19.72 16.38
24 L Unilocular 45.18 48.59 + +
25 R Unilocular 29.43 18.53
26 R Unilocular 39.85 39.04
27 R Multilocular 43.29 22.30 +
28 L Unilocular 22.05 22.98 +
29 R Unilocular 28.63 28.63 +

BP, buccopalatal; MD, mesiodistal; R, right; L, left.

The lesion size refers to the most extended axial length on cone-beam computed tomography.

Correlation between the two groups

Clinical/Radiographic features Period after maxillary sinus operation p-value
Under 24 year (n=11) Over 24 year (n=14)
Symptom
Non specific 2 2
Pain 7 11 0.409
Swelling 3 7 0.250
Toothache 0 2 0.191
Pus discharge 1 4 0.227
Abnormal sensation 1 0 0.250
Dullness 1 1 0.859
Expansion
Zygoma 4 4 0.678
Ethmoid 0 0
Orbit 0 0
Root communication 6 11 0.201
Secondary cyst 3 1 0.404
Length (mm)
Buccopalatal 0.031*
<15 6 1
15-30 3 9
30< 2 4
Mesiodistal 0.897
<15 0 0
15-30 6 8
30< 5 6

*p-value was considered as significant when p-value<0.05.

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