From the Guidelines
Treatment of a periapical cyst extending into the maxillary sinus typically requires endodontic therapy followed by surgical intervention, with the primary approach involving root canal treatment of the affected tooth to eliminate the source of infection, followed by enucleation of the cyst through an intraoral approach, as supported by the most recent and highest quality study available 1. The primary goal of treatment is to eliminate the source of infection and prevent complications such as sinusitis, oroantral fistula, or spreading infection.
- The treatment approach involves: + Root canal treatment of the affected tooth to eliminate the source of infection + Enucleation of the cyst through an intraoral approach + Prophylactic antibiotics such as amoxicillin 500mg three times daily for 7-10 days, or clindamycin 300mg four times daily for patients with penicillin allergy, as recommended by 2 + Pain management with ibuprofen 400-600mg every 6 hours as needed, supplemented with acetaminophen 500mg every 6 hours if necessary
- If the cyst has significantly invaded the maxillary sinus, an endoscopic approach may be required with otolaryngology consultation, as suggested by 3
- Following surgery, saline nasal irrigation twice daily and avoiding nose-blowing for 2 weeks are essential to prevent complications, as noted in 1 The surgical procedure involves creating a mucoperiosteal flap, removing bone to access the cyst, complete cyst removal while preserving the sinus membrane when possible, and primary closure. This comprehensive approach is necessary because periapical cysts result from chronic inflammation of pulpal origin, with bacterial toxins stimulating epithelial cell proliferation and cyst formation, as explained in 4. Without complete removal, recurrence is likely, and inadequate treatment may lead to sinusitis, oroantral fistula, or spreading infection, highlighting the importance of proper treatment as emphasized in 5.
From the Research
Treatment Options for Periapical Cysts Involving the Maxillary Sinus
- Conservative root canal treatment can be an effective treatment option for periapical cysts involving the maxillary sinus, as seen in a case report where a large cyst-like periradicular lesion was treated with conservative root canal treatment, resulting in complete resolution of the sinus tract and periapical healing 6.
- Decompression and endodontic therapy can also be used to treat large periapical cyst-like lesions, with a case report showing significant reduction in lesion size and active signs of healing at 12 months 7.
- Marsupialization and decompression can be used as a conservative approach to reduce the size of the lesion, followed by surgical endodontic therapy and enucleation if necessary 8.
- Surgical endodontics, removal of the problematic tooth, enucleation with primary closure, or marsupialization and enucleation are also treatment options for radicular cysts, including those that spread across the maxillary sinus 9.
- A case report of a large radicular cyst involving the entire maxillary sinus was treated with conservative treatment without any postoperative complications, highlighting the importance of appropriate diagnosis and treatment of the infected root canal system 10.
Key Considerations
- The treatment of periapical cysts involving the maxillary sinus should be as conservative as possible and by endodontic means, as they are lesions of endodontic origin 7.
- Large surgical interventions may be unnecessary in cases where endodontic treatment can be performed 7.
- The choice of treatment depends on the size and location of the lesion, as well as the presence of any symptoms or complications 8, 9.