Case Study: Maxillary Keratocystic Odontogenic Tumor with Sinus Involvement
3D technology from Planmeca provides expediency in uploading radiographic fi les for immediate diagnosis and treatment.
A 60-year-old Caucasian female was referred from her general dentist with a chief complaint of diffuse pain in the maxillary right side of her face. There was some discomfort when chewing. The patient reported having pain and a root canal completed on tooth No. 3 in 1994. The symptoms continued and the patient sequentially had an apicoectomy, extraction, and a fixed bridge spanning from teeth Nos. 2 to 4. The patient also remembers having some type of hard mass removed from her sinus in the 1980s. The patient reports a history of having a bad gagging reflex, making it hard to take dental radiographs through-out her lifetime.
Teeth Nos. 2 to 6 responded to a cold test using an ice chip. Tooth No. 2 was tender to percussion. All mandibular teeth and gingival tissue tested within normal limits. The right tuberosity area was depressible.
A traditional periapical film was attempted and failed due to the patient’s gag reflex. A Planmeca 2D panorex was taken. The panorex demonstrates the maxillary right tuberosity is radiolucent and expanded, plus degenerative joint disease, right TMJ (Figure 1). A Planmeca CBCT 8 × 8 image at 90kV/12mA/12.3s was rendered (Figure 2). The CBCT DICOM images were uploaded to BeamReaders for radiographic interpretation. There was a gross expansion of the right maxillary tuberosity distal to tooth No. 2 with extreme thinning of the cortex on all sides (Figure 3). A radiolucent area extended medially into the palate and posteriorly into the pterygomaxillary area (Figure 4). Locules extend anteriorly to the second molar. The floor of the sinus is elevated by the lesion distal to No. 2 in its normal location anterior to the tuberosity. The medial wall of the right sinus is missing, although this may be a result of the previous surgery. The margins of the lesion appear curved and well defined, with an occasional suggestion of fine wispy septa within the lesion (Figure 5).
The position of the lesion in the right maxillary tuberosity rather than the maxillary sinus would lead us to believe it is from a history of odontogenic origin. The lesion gives the appearance of a keratocystic odontogenic tumor. Being that the lesion is located only to the maxillary jaw, ameloblastoma could be more likely than myxoma, central giant cell lesions, and nevoid basal carcinoma. The patient was referred to the oral surgeon for consult and treatment. A preliminary distal wedge excisional biopsy was performed and sent for biopsy. The biopsy showed stratified squamous epithelium covering a core of well-vascularized fibrous connective tissue with a dense infiltrate of neutrophils, lymphocytes, and plasma cells. The pathologist’s impression was acute inflammatory reaction. The patient was referred to an ENT for consultation and treatment. The patient underwent a right Caldwell-Luc procedure. A cystic mass with inspissated secretions was excised. Fragments of benign, partially squamous, and sinonasal-type epithelium-lined cyst wall with dense fibrosis marked inflammation. After discussion, with correlation to radiographic results, the final diagnosis was keratocystic odontogenic tumor (KCOT/OKC).
Having a multidisciplinary approach to diagnosing and treating patients provides patients with the most efficient treatment and predictable prognosis. Patients who have special needs, such as gag reflexes, autism, and Down syndrome, may not be able to tolerate intraoral radiographs. From an endodontic standpoint, many patients are referred for pain diagnosing. An 8 × 8 cm CBCT that can render both a traditional 2D and 3D image offers the advantage of bilateral orthognathic and sinus diagnosis capability. Being able to select an area on a 2D panorex allows us to scout a particular quadrant, or from TMJ to TMJ. Radiographic interpretation for diagnosis will always have its academic foundation based on traditional radiology. Planmeca ProMax 3D technology provided expediency to upload radiographic files to the cloud or via the Internet for immediate diagnosis and treatment from the appropriate specialists. This allows much clearer communication between the endodontic specialist, the maxillofacial surgeon, and the ENT.
The KCOT is an aggressive tumor with a high reoccurrence rate. Diagnosis requires comprehensive communication from different modalities of medicine and dentistry. CBCT has definitively enhanced these avenues for a more thorough treatment approach for patients.