A Large Follicular Dentigerous Cyst: A New Multi-portal Access: Intraoral and Endoscopic Technique

Background: The standard treatment for a dentigerous cyst of maxilla is a surgical enucleation, the extraction of the tooth. In the case of cysts involving the maxillary sinus, a Caldwell-Luc approach is used. In case of large cysts, its marsupialization is carried out in order to reduce the bone defect, followed by enucleation and extraction of the tooth. Methods: This is a case of a large follicular dentigerous cyst of upper jaw with 18 ectopic tooth within the maxillary sinus, treated in our Unit. Results: We decided to perform a multi-portal access, the intraoral endoscopic-assisted technique; an intraoral approach has been performed, but less demolishing than the routine intraoral approach, through the anterior wall of the maxillary sinus, already eroded by the lesion. The lesion was very large, occupying the entire maxillary cavity. For this reason, by means of the intraoral approach alone, it was extremely difficult to remove the lesion in its entirety. The endoscopic-assisted technique was combined with intraoral approach. The lesion extended to the maxillary ostium. This did not allow to reach the ostium through the classic endoscopic approach. Endonasal endoscopic access was used both to enucleate the cyst, that was adherent to the orbital floor and soft tissues of the OMC (osteomeatal complex), and to restore the physiological drainage of the maxillary sinus. Conclusions: We decided to perform a combined intraoral and endoscopic approach to allow a complete excision of the cystic lesion, without being very demolishing and taking advantage of the bone erosion already caused by the large cyst.