Surgical and prosthetic management of an invasive radicular cyst. Ten year follow-up clinical case

OBJECTIVES: The aim of this report is to visualize the implications which may arise from an untreated maxillary odontogenic radicular cyst. This may initially appear like an ordinary lesion however it reaches an advanced stage of maturation and invasion, therefore surgical implications should help readers consider treatment strategy and timing when observing simple lesions in everyday practice. In this case, the invasion of the left maxillary sinus could lead to severe prosthetic implications potentially leaving the patient with few treatment options for full rehabilitation.
Moreover, the surgical protocols, regarding both enucleation stage and implant positioning stage, highlight the accomplishment of desired rehabilitation result by careful management of available tissues and preservation of healthy bone borders.

MATERIALS AND METHODS: The first stage in this complex case management was the surgical enucleation of the invading lesion, carried out by opening a large flap to expose the entirety of the lesion. Once the cyst was enucleated, the second stage involved cleaning the bony margins of to avoid a potential relapse. The area was stabilized and a six-month remineralization time was planned before an implant placement. Lastly, 4 pure conical connection implants were placed and after reaching an optimal osteointegration and maturation, these were rehabilitated with a metallo-ceramic 4 unit bridge.

RESULTS: The surgical management of the initial cystic lesion allowed a mineralization and maturation of the residual bone, enabling the closure of the sinus following a complete surgical invasion to decontaminate from the invading lesion. The interested area was histologically excluded from being a cancerous lesion and stably reformed a new Schneiderian membrane without any post-operative complications. This ensured that the patient could regain aesthetic and functional parameters of the interested area with an implant-supported fixed prosthetic solution.

CONCLUSIONS: The surgical management during the enucleation stage and implant placement stage are not to be underestimated. Thanks to this, 4 pure conometric connection implants were placed, giving the final rehabilitation characteristics that ensure long lasting soft and hard tissue integration and maintenance.

CLINICAL SIGNIFICANCE:  This is an exemplary case of a severe bone defect caused by the lesion’s invasive nature. Invasive lesions can often compromise hard tissue stability and integrity that are difficult to manage due to the complex prosthetic steps that follow the healing process.
Big bony defects pose a challenge in the implant placement stage and produce wide gaps between prosthesis and soft tissues.
These give the patient less access for sanitizing the rehabilitations, especially when these are fixed bridges or crowns.
In relation to this minimal surgical trauma, a correct implant selection and placement is able to produce optimal prosthetic rehabilitation. The implants can maintain their integrity and stability even when subject to suboptimal clinical conditions or long follow-up periods.

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