- Email: [email protected]
A large dentigerous cyst associated with a supernumerary tooth
119
NEWHOUSE ET AL.
straight cut to the pterygoid plates and, in combination with an 8 mm ostectomy, categorically placed the superior cut well into the pterygopalatine fossa. Notably, profuse hemorrhage was not encountered during malleting of the pterygomaxillary junction, but only when the down fracture was effected. We speculate that with pterygomaxillary dysjunction the right pterygoid complex was detached, and a sharp bony edge was forced posteriorly, lacerating the vessels during down fracture manipulation. With the loss of a posterior point of stabilization for the maxilla (with fracture of the pterygoids from the sphenoid base), the entire pterygomaxillary complex was possibly forced posteriorly during the down-fracturing maneuver. Speculation on the mechanism of injury to nerves X and XII is also warranted. The nerves are in proximity to the involved vessels, situated medially and between them in the upper neck. The injury possibly occurred with maxillary down fracture, insertion of pressure packs, or during exposure for treatment of the A-V fistula. The last possibility is
unlikely, as the nerves were identified and protected during this procedure. The decision to treat the A-V fistula immediately can be credited with averting the further disaster of additional major hemorrhage. At surgery, the internaljugular vein was found dilated and near rupture. Conclusion
A unique complication of elective orthognathic surgery has been reported, This case demonstrates that even though most major hemorrhagic episodes during midfacial surgery are due to maxillary artery trauma the possibility of internal carotid artery hemorrhage is a possible complication. References I. Converse JM, Wood-Smith 0, McCarthy JG: Report on a
series of 50 craniofacial operations. Plast Reconstr Surg 55:283-293, 1975 2. Turvey TA, Fonseca RJ: The anatomy of the internal maxillary artery in the pterygopalatine fossa: its relationship to maxillary surgery. J Oral Surg 38:92-95, 1980
A Large Dentigerous Cyst Associated with a Supernumerary Tooth DOUGLAS S. MOST, DDS,* AND EDWARD P. ROY, DMDt Dentigerous cysts are a common pathologic entity. However, when associated with a supernumerary tooth, they are not common. Our report is unusual because it demonstrates a dentigerous cyst associated with a supernumerary tooth (central incisor) that involved both maxillary sinuses. Our search of the English language literature of the past ten years failed to reveal a similar case. Report of a Case A 30-year-old oriental man, well developed and well nourished, reported pain in the mandibular right third molar area and swelling of the right maxillary mucogingival fold area. Examination revealed a mesioangular mandibular right third molar and an obvious swelling of the buccal aspect of the alveolus in the maxillary right quadrant, with some obliteration of the mucogingival fold. Upon palpation, there was obvious movement of the un-
* Oral and maxillofacial surgeon in private practice. t General practitioner in private practice. Address correspondence and reprint requests to Dr. Douglas Most: Parkview Professional Building, Brunswick, ME 04011.
derlying cortical bone from the second molar to the canine. This entire quadrant was asymptomatic. All of the maxillary teeth were vital; none were missing. A panoramic radiograph (Fig. 1) revealed a large radiolucency that apparently occupied the entire right antrum, extended across the midline, and occupied approximately one half of the left antrum. A radiopaque toothlike structure was noted just to the left of midline. Additional radiographs (posteroanterior, lateral, and Waters' views) were obtained. The Waters' view (Fig. 2) confirmed the extent of the lesion and revealed destruction of the right lateral wall of the sinus. The patient was hospitalized, and, while he was under general anesthesia, we performed the following procedure. A full-thickness mucoperiosteal flap was raised extending from the right tuberosity area, across midline, to the distal aspect of the maxillary left first premolar. The incision followed the gingival sulcus. The underlying cortical plate in the right maxillary region was bulging. Using a curette and ronguers, we removed this thin bony plate. Immediately adjacent to the bone was a "sac/ike" lining. Decortication was performed from the maxillary right second molar to the maxillary right canine. Approximately 1 ern of sound alveolar bone was left intact to insure support of the teeth. The cyst was inadvertently ruptured, and copious amounts of thick brown material
0278-2391/82/0200'0119 SOO.4O © American Association of Oral and Maxillofacial Surgeons
120
DENTIGEROUS CYST
FIGURE I. Panoramic radiograph of radiolucency that occupied the right antrum, extended across midline, and occupied one half of the left antrum.
in the previous area, a small perforation was noted. This opening was enlarged and again the "saclike" lining was found to be adjacent to the bone. Using a curette, we easily peeled the lesion from this side, pushed it across midline, and brought it out of the surgical opening on the right side. The lesion extended to the posterior wall of the antrum on the right side, this section of the lesion did not enucleate easily. The sinuses were packed with vaselinecoated gauze and a nasal antrostomy was created to facilitate eventual removal of the pack. The overlying gingival tissues were coadapted and sutured. The postoperative course was uneventful. The patient's treatment was followed for several months until he left the country. The teeth in the maxilla remained asymptomatic.
Pathology Report
FIGURE 2. Waters' view confirming extent oflesion.
Gross specimens consisted of an irregular, wrinkled soft gray-tan piece of tissue, 9 x 1.5 x 0.8 em and a rudimentary tooth I em in greatest dimension. The tooth most closely resembled a central incisor with a dwarfed root. Microscopic study revealed a cavitary lesion lined in part by thin squamous epithelium consistent with a diagnosis of dentigerous cyst. Summary
were expelled. A toothlike object was removed from inside the cyst. It was thought best not to decorticate across midline, so a new area was started in the maxillary left lateral canine area. Although the bone was not as thin as
A case of a supernumerary tooth and associated dentigerous cyst that involved both maxillary sinuses is reported.
NEWHOUSE ET AL.
straight cut to the pterygoid plates and, in combination with an 8 mm ostectomy, categorically placed the superior cut well into the pterygopalatine fossa. Notably, profuse hemorrhage was not encountered during malleting of the pterygomaxillary junction, but only when the down fracture was effected. We speculate that with pterygomaxillary dysjunction the right pterygoid complex was detached, and a sharp bony edge was forced posteriorly, lacerating the vessels during down fracture manipulation. With the loss of a posterior point of stabilization for the maxilla (with fracture of the pterygoids from the sphenoid base), the entire pterygomaxillary complex was possibly forced posteriorly during the down-fracturing maneuver. Speculation on the mechanism of injury to nerves X and XII is also warranted. The nerves are in proximity to the involved vessels, situated medially and between them in the upper neck. The injury possibly occurred with maxillary down fracture, insertion of pressure packs, or during exposure for treatment of the A-V fistula. The last possibility is
unlikely, as the nerves were identified and protected during this procedure. The decision to treat the A-V fistula immediately can be credited with averting the further disaster of additional major hemorrhage. At surgery, the internaljugular vein was found dilated and near rupture. Conclusion
A unique complication of elective orthognathic surgery has been reported, This case demonstrates that even though most major hemorrhagic episodes during midfacial surgery are due to maxillary artery trauma the possibility of internal carotid artery hemorrhage is a possible complication. References I. Converse JM, Wood-Smith 0, McCarthy JG: Report on a
series of 50 craniofacial operations. Plast Reconstr Surg 55:283-293, 1975 2. Turvey TA, Fonseca RJ: The anatomy of the internal maxillary artery in the pterygopalatine fossa: its relationship to maxillary surgery. J Oral Surg 38:92-95, 1980
A Large Dentigerous Cyst Associated with a Supernumerary Tooth DOUGLAS S. MOST, DDS,* AND EDWARD P. ROY, DMDt Dentigerous cysts are a common pathologic entity. However, when associated with a supernumerary tooth, they are not common. Our report is unusual because it demonstrates a dentigerous cyst associated with a supernumerary tooth (central incisor) that involved both maxillary sinuses. Our search of the English language literature of the past ten years failed to reveal a similar case. Report of a Case A 30-year-old oriental man, well developed and well nourished, reported pain in the mandibular right third molar area and swelling of the right maxillary mucogingival fold area. Examination revealed a mesioangular mandibular right third molar and an obvious swelling of the buccal aspect of the alveolus in the maxillary right quadrant, with some obliteration of the mucogingival fold. Upon palpation, there was obvious movement of the un-
* Oral and maxillofacial surgeon in private practice. t General practitioner in private practice. Address correspondence and reprint requests to Dr. Douglas Most: Parkview Professional Building, Brunswick, ME 04011.
derlying cortical bone from the second molar to the canine. This entire quadrant was asymptomatic. All of the maxillary teeth were vital; none were missing. A panoramic radiograph (Fig. 1) revealed a large radiolucency that apparently occupied the entire right antrum, extended across the midline, and occupied approximately one half of the left antrum. A radiopaque toothlike structure was noted just to the left of midline. Additional radiographs (posteroanterior, lateral, and Waters' views) were obtained. The Waters' view (Fig. 2) confirmed the extent of the lesion and revealed destruction of the right lateral wall of the sinus. The patient was hospitalized, and, while he was under general anesthesia, we performed the following procedure. A full-thickness mucoperiosteal flap was raised extending from the right tuberosity area, across midline, to the distal aspect of the maxillary left first premolar. The incision followed the gingival sulcus. The underlying cortical plate in the right maxillary region was bulging. Using a curette and ronguers, we removed this thin bony plate. Immediately adjacent to the bone was a "sac/ike" lining. Decortication was performed from the maxillary right second molar to the maxillary right canine. Approximately 1 ern of sound alveolar bone was left intact to insure support of the teeth. The cyst was inadvertently ruptured, and copious amounts of thick brown material
0278-2391/82/0200'0119 SOO.4O © American Association of Oral and Maxillofacial Surgeons
120
DENTIGEROUS CYST
FIGURE I. Panoramic radiograph of radiolucency that occupied the right antrum, extended across midline, and occupied one half of the left antrum.
in the previous area, a small perforation was noted. This opening was enlarged and again the "saclike" lining was found to be adjacent to the bone. Using a curette, we easily peeled the lesion from this side, pushed it across midline, and brought it out of the surgical opening on the right side. The lesion extended to the posterior wall of the antrum on the right side, this section of the lesion did not enucleate easily. The sinuses were packed with vaselinecoated gauze and a nasal antrostomy was created to facilitate eventual removal of the pack. The overlying gingival tissues were coadapted and sutured. The postoperative course was uneventful. The patient's treatment was followed for several months until he left the country. The teeth in the maxilla remained asymptomatic.
Pathology Report
FIGURE 2. Waters' view confirming extent oflesion.
Gross specimens consisted of an irregular, wrinkled soft gray-tan piece of tissue, 9 x 1.5 x 0.8 em and a rudimentary tooth I em in greatest dimension. The tooth most closely resembled a central incisor with a dwarfed root. Microscopic study revealed a cavitary lesion lined in part by thin squamous epithelium consistent with a diagnosis of dentigerous cyst. Summary
were expelled. A toothlike object was removed from inside the cyst. It was thought best not to decorticate across midline, so a new area was started in the maxillary left lateral canine area. Although the bone was not as thin as
A case of a supernumerary tooth and associated dentigerous cyst that involved both maxillary sinuses is reported.