Conservative approach to recurrent calcifying cystic odontogenic tumor occupying the maxillary sinus: a case report

Unusual Association of Calcifying Cystic Odontogenic Tumor with Compound Odontoma and Ameloblastoma: Case Report and Review of the Literature

Calcifying cystic odontogenic tumor (CCOT) is a rare odontogenic cyst accounts for <2% of all odontogenic cysts. Simple unicystic CCOT is commonly encountered accounts for 65%, whereas other forms of CCOT are <3%. CCOT is associated with two or more odontogenic tumors, it is called combined odontogenic lesions or hybrid lesions. The aim of the present article is to report a rare case of CCOT and highlighting the clinical feature and treatment aspects of combined lesions. A 25-year-old female complained of pain and swelling in the left maxilla for 6 months. Examination revealed diffuse swelling in the maxilla, firm in consistency, and tender on palpation. Panoramic radiograph showed impacted canine with multiple radiopaque structures and well-defined lesion in the maxillary sinus. The lesion was surgically removed and histopathologically diagnosed as CCOT with compound odontoma and ameloblastoma. Pub Med database search from 1978 to June 2020 revealed only three case reports of combined odontogenic tumors associated with CCOT.

Active decompression and distraction sugosteogenesis for the treatment of calcifying odontogenic cyst

The calcifying odontogenic cyst is as a benign, rare developmental odontogenic cyst with a wide range of histologic characteristics. It may present along with other odontogenic pathologies such as odontoma, ameloblastoma, adenomatoid odontogenic tumor, ameloblastic fibroma, and ameloblastic fibro-odontoma. Clinically, it can be an either intra- or extraosseous painless swelling that can produce cortical expansion. It affects mostly the anterior area of the mandible. Radiographically, it appears as a well-circumscribed unilocular radiolucency containing flecks of indistinct radiopacities. In about one third of cases, an impacted tooth is associated. In this paper, we employ a patient with an enormous calcifying odontogenic cyst to review both the pathology and active decompression and distraction sugosteogenesis, a novel technique employed to treat odontogenic entities. This dual approach usually results in an accelerated bone healing (sugosteogenesis), partial removal of the cystic epithelium, thickening of the wall, and migration of chronic inflammatory cells which triggered epithelial modulation, ultimately causing a realignment in the biologic behavior of the lesion.

Marsupialization before enucleation as a treatment strategy for a large calcifying odontogenic cyst: Case report

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Two-stage treatment strategies are effective for large lesions.

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Marsupialisation promotes lesion decompression and decreases lesion volume.

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Reduction of the lesion allows lower risk enucleation of the structures.

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This strategy prevents damage to important anatomical structures.

Introduction

Odontogenic pathological lesions can generally be divided into cysts and tumors. Calcifying odontogenic cyst (COC) is a non-aggressive odontogenic cyst, however, in a few occasions, COC can show excessive growth and destruction. This study describes an uncommon aggressive presentation of a large COC and discusses the treatment strategies used to achieve a favorable result.

Presentation of case

A 11-year-old child sought treatment for a painless growth on his mandible that caused facial asymmetry. On clinical and imaging examination, a large radiolucent lesion was observed in a panoramic x-ray involving the right side of the mandible. Radiopaque areas were observed within the lesion. Treatment comprised of an initial marsupialization followed by surgical removal of the lesion. Follow up extended for more than 10 years and no signs of recurrence were observed.

Discussion

Initial marsupialization was successfully employed in order to decrease the lesion, inducing bone formation, and reducing the risk of mandibular fracture and inferior alveolar nerve damage. Four months after marsupialization, the lesion substantially reduced its volume and enucleation with peripheral ostectomy was carried out. This approach allowed a safer surgical removal of the lesion and achieve an excellent result.

Conclusion

Although some authors consider marsupialization as an unnecessary step that delays final treatment, when well indicated, it facilitates surgical treatment, promotes and preserves normal tissues, reduces the necessity of surgical reconstruction and costs, yet showing excellent results.

Perfil clínico e histopatológico do cisto odontogênico calcificante: relato de caso

O cisto odontogênico calcificante (COC) foi primeiramente descrito em 1962, considerado como condição patológica benigna de ocorrência rara em maxila e mandíbula, caracterizado por revestimento cístico de células epiteliais odontogênicas contendo células fantasmas com propensão a regiões de calcificação.  Neste artigo, descreveu-se a configuração clínica e histopatológica do COC por meio de relato de caso submetido a tratamento cirúrgico e acompanhamento pós-operatório. Uma paciente de 11 anos apresentou um aumento de volume em região maxilar a esquerda próxima ao sulco nasolabial sem sintomatologia dolorosa. Os exames radiográficos indicaram lesão radiolúcida, bem circunscrita e expansiva em maxila, que foi submetida a enucleação associada a ostectomia marginal das paredes corticais ósseas. O quadro histopatológico foi caracterizado por revestimento cístico com epitélio odontogênico ameloblástico, ninhos espalhados de células fantasmas e regiões eosinofílicas de material compatível com dentinóide. O relato de caso apresentou perfil clínico de COC, que pode ser confundido com outras lesões císticas ou tumorais, sendo essencial diagnóstico por meio de análise histopatológica. A abordagem cirúrgica proporcionou diagnóstico e tratamento. Após acompanhamento clínico e radiográfico, não houve recorrência do COC.