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Bilateral dentigerous cysts of the maxilla
EXODONTIA .
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BILATERAL
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DENTIGEROUS
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CYSTS OF THE MAXILLA
Report
of a Case
k:dumd
P. Henef er, D.L).S.,* Philadelphia.,
Pa.
INTRODUCTION
N THE roentgenogram of an impacted or unerupted tooth there is normally a dark space of variable width surrounding the crown. This soft-tissue shadow is produced by a “cap” of fibrous connective tissue which is a normal part of the tooth follicle. Separating the connective tissue from the enamel surface of the crown is an epithelial layer, the remnant of t,he enamel-forming organ. This is composed of several rows of stratified squamous epithelial cells united to the enamel of the tooth through an organic connection.4 When this layer undergoes cystic degeneration the fluid that is elaborated is discharged bet.ween enamel and cpithelium, causing displacement of the soft tissues.8* I” The early stages of cyst formation cannot be detected radiographically. It is not until a cyst of rather significant size has formed that the clinician can accurately recognize or predict cystic degeneration upon x-ray examination. Dentigerous cysts characteristically develop without symptoms, and the absancc of early objective or subjective indications frequently allows for extensive destruction of adjacent structures. 2l B Infection of the contents of the cyst OCCUPS on occasion, usually upon communication with the oral cavity.4 Bhaskar and I,ill.yl state that impacted teeth can, and usually do, become involved in cystic formation. Therefore, when a dentist decides to retain an impact.ed tooth he must assume the responsibility for the potential development of a denbigerous cyst. In addition, the epithelial cells lining the cystic cavity may proliferate to form an ameloblastoma, a lesion that often requires a more estensive surgical procedure. An excised dentigerous cyst should always be suhmittcd to the pathologist for microscopic examination to rule out ameloblastic change. The following case report demonstrates that the potential for cystic degeneration exists when impacted t.eet.h are retained. While a number of cases I
*Associate
in Oral
Surgery. 296
BILATERAL
Volume 17 Number 3
DENTIGEROUS
CYSTS OF MAXILLA
297
of multiple dentigerous cysts have been reported,2l 3*5-7vgyI1 bilateral dentigerous cyst formation about the maxillary third molars is unusual. CASE
REPORT
A 52-year-old Negro woman returned to the University of Pennsylvania School of Dentistry for replacement of discolored facings on a maxillary anterior fixed bridge. A full-mouth roentgenographic study revealed radlolucencies about the two maxillary third molars (Fig. I). The provisional diagnosis of bilateral maxillary dentigerous cysts was made on the basis of x-ray appearance. The patient was admitted to Presbyterian Hospital in Philadelphia for surgical removal of the cysts. Physical examination revealed nothing of an unusual nature, and laboratory studies of blood and urine revealed values within normal limits. In the operating room, after induction of nasoendotracheal general anesthesia, the mucoperiosteum over the left maxillary tuberosity was incised and reflected, exposing a thin but continuous layer of alveolar cortical bone. This was readily removed when lifted away from the underlying cyst membrane. When enough bone had been removed to allow adequate access, a large-bowl eurette was introduced to free the cyst membrane from the walls of the bone cavity. The impacted tooth itself could not be visualized, but cautious application of elevators allowed it to be delivered with the cyst attached. The wall of the cyst had ruptured during removal, releasing a clear yellowish fluid. Careful examination of the specimen revealed that the cyst had been completely removed. The bone cavity was irrigated with
Fig.
l.-Roentgenograms teeth.
Arrows
demonstrating bilateral cyst formation and displacement of impacted
indicate
extent
of cystic
destructlon
of maxillary
alveolus.
sterile isotonic saline solution :lnd dressed light.ly wit.h mcdic~ntoil iodoform gauze. The ~rll’l tissues were replaced au11 :~l’~)rorinlsltc~l with intwruptcd 1-O silk sutures. rl’hc cyst and il s related t.ooth on the right siclcnww rcmovrtl in an i&did mannw, although the overlying bone was incomplete and tllcn fluid contwIt of the cyst was found to lw purul~mt. The patient had an unc,onlplicat.c~d postopwative course. The maxillary sinuses and adjacent teeth had not been dist,urbcd during the surgical proccdurc. The pathologist’s report confirmed the preoperat.ive diagnosis. The microscopic dcscript.ion included reference to twn cysts with maximum dimensions of 1.5 cm. and 2.0 cm., lind 1vit.h normal-appearing stratified squamous epithelium of varial)le thic*kuess. So evidence of malignant tumor was noted in the levels of tissue examined miwosc~opic!all~.
The history of this case indicates that two impacted third molars were rctained while extensive fixed bridgework was constructed for the adjacent teeth. 13uring the subsequent 7 years cystic degeneration developed about both t.eeth. It was fortunate that the process was recognized and intercepted before more extensive destruction of adjacent structures had occurred. The potential hazard of retaining impacted teet.h is obvious and should not be overlooked. REFERENCES 1. Bhaskar, 8. N., and Lilly, Gilbert E.: Dentigerous Cysts; Report of 30 Cases, J. Dist. Columbia Sot. 38: 3-5, 1963. 2. Caldwell, J. B., and Thompson, H. C.: Bilateral Multiloeular Follieular Cysts of the Maxilla and Mandible, J. Oral Surg. 13: 102-107, 1955. 3. Folkins, J. A.: Multiple Dentigerous Cysts in a Child of Ten, J. Canad. Dent. A. 26: 140-145, 1959. 4. Kronfeld, R., and Boyle, P. E. (editors) : Histopathology of the Teeth and Their Surrounding Structures, ed. 3, Philadelphia, 1949, Lea & Febiger. 5. Pekarsky, R. L.: Dentigerous Cysts of the Jaw With Unerupted Teeth, ORAL BURG.,ORAL MED. & ORAL PATH. 3: 860-867, 1950. 6. Pizer, M. E.: Dentigerous Cyst of the Wall of the Maxillary Sinus, ORAL SU&G., OXAL MED. & ORAL PATH. 7: 1210-1211, 1954. 7. Scales, J. L., and Calhoun, N. R.: Bilateral Impacted Third and Supernumerary Molars Associated With a Dentigerous Cyst, Items Interest 74: 1121-1123, 1952. 8. Shafer, W. G., Hine, M. K., and Levy, B. M. : A Textbook of Oral Pathology, ed. 2, Philadelphia, 1963, W. B. Saunders Company. 9. Sharland, R. J.: Case of Multiple Dentigerous Cysts of the Mandible, Brit. D. J. 84: 35-36, 1948. 10. Sicher, Harry (editor) : Orban’s Oral Histology and Embryology, ed. 5, St. Louis, 1962, The C. V. Mosby Company. 11. Uhler, I. V.: Bilateral Dentigerous Cysts, J. Am. Dent. A. 37: 729-730, 1948.
.
.
.
BILATERAL
.
.
.
.
.
DENTIGEROUS
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
CYSTS OF THE MAXILLA
Report
of a Case
k:dumd
P. Henef er, D.L).S.,* Philadelphia.,
Pa.
INTRODUCTION
N THE roentgenogram of an impacted or unerupted tooth there is normally a dark space of variable width surrounding the crown. This soft-tissue shadow is produced by a “cap” of fibrous connective tissue which is a normal part of the tooth follicle. Separating the connective tissue from the enamel surface of the crown is an epithelial layer, the remnant of t,he enamel-forming organ. This is composed of several rows of stratified squamous epithelial cells united to the enamel of the tooth through an organic connection.4 When this layer undergoes cystic degeneration the fluid that is elaborated is discharged bet.ween enamel and cpithelium, causing displacement of the soft tissues.8* I” The early stages of cyst formation cannot be detected radiographically. It is not until a cyst of rather significant size has formed that the clinician can accurately recognize or predict cystic degeneration upon x-ray examination. Dentigerous cysts characteristically develop without symptoms, and the absancc of early objective or subjective indications frequently allows for extensive destruction of adjacent structures. 2l B Infection of the contents of the cyst OCCUPS on occasion, usually upon communication with the oral cavity.4 Bhaskar and I,ill.yl state that impacted teeth can, and usually do, become involved in cystic formation. Therefore, when a dentist decides to retain an impact.ed tooth he must assume the responsibility for the potential development of a denbigerous cyst. In addition, the epithelial cells lining the cystic cavity may proliferate to form an ameloblastoma, a lesion that often requires a more estensive surgical procedure. An excised dentigerous cyst should always be suhmittcd to the pathologist for microscopic examination to rule out ameloblastic change. The following case report demonstrates that the potential for cystic degeneration exists when impacted t.eet.h are retained. While a number of cases I
*Associate
in Oral
Surgery. 296
BILATERAL
Volume 17 Number 3
DENTIGEROUS
CYSTS OF MAXILLA
297
of multiple dentigerous cysts have been reported,2l 3*5-7vgyI1 bilateral dentigerous cyst formation about the maxillary third molars is unusual. CASE
REPORT
A 52-year-old Negro woman returned to the University of Pennsylvania School of Dentistry for replacement of discolored facings on a maxillary anterior fixed bridge. A full-mouth roentgenographic study revealed radlolucencies about the two maxillary third molars (Fig. I). The provisional diagnosis of bilateral maxillary dentigerous cysts was made on the basis of x-ray appearance. The patient was admitted to Presbyterian Hospital in Philadelphia for surgical removal of the cysts. Physical examination revealed nothing of an unusual nature, and laboratory studies of blood and urine revealed values within normal limits. In the operating room, after induction of nasoendotracheal general anesthesia, the mucoperiosteum over the left maxillary tuberosity was incised and reflected, exposing a thin but continuous layer of alveolar cortical bone. This was readily removed when lifted away from the underlying cyst membrane. When enough bone had been removed to allow adequate access, a large-bowl eurette was introduced to free the cyst membrane from the walls of the bone cavity. The impacted tooth itself could not be visualized, but cautious application of elevators allowed it to be delivered with the cyst attached. The wall of the cyst had ruptured during removal, releasing a clear yellowish fluid. Careful examination of the specimen revealed that the cyst had been completely removed. The bone cavity was irrigated with
Fig.
l.-Roentgenograms teeth.
Arrows
demonstrating bilateral cyst formation and displacement of impacted
indicate
extent
of cystic
destructlon
of maxillary
alveolus.
sterile isotonic saline solution :lnd dressed light.ly wit.h mcdic~ntoil iodoform gauze. The ~rll’l tissues were replaced au11 :~l’~)rorinlsltc~l with intwruptcd 1-O silk sutures. rl’hc cyst and il s related t.ooth on the right siclcnww rcmovrtl in an i&did mannw, although the overlying bone was incomplete and tllcn fluid contwIt of the cyst was found to lw purul~mt. The patient had an unc,onlplicat.c~d postopwative course. The maxillary sinuses and adjacent teeth had not been dist,urbcd during the surgical proccdurc. The pathologist’s report confirmed the preoperat.ive diagnosis. The microscopic dcscript.ion included reference to twn cysts with maximum dimensions of 1.5 cm. and 2.0 cm., lind 1vit.h normal-appearing stratified squamous epithelium of varial)le thic*kuess. So evidence of malignant tumor was noted in the levels of tissue examined miwosc~opic!all~.
The history of this case indicates that two impacted third molars were rctained while extensive fixed bridgework was constructed for the adjacent teeth. 13uring the subsequent 7 years cystic degeneration developed about both t.eeth. It was fortunate that the process was recognized and intercepted before more extensive destruction of adjacent structures had occurred. The potential hazard of retaining impacted teet.h is obvious and should not be overlooked. REFERENCES 1. Bhaskar, 8. N., and Lilly, Gilbert E.: Dentigerous Cysts; Report of 30 Cases, J. Dist. Columbia Sot. 38: 3-5, 1963. 2. Caldwell, J. B., and Thompson, H. C.: Bilateral Multiloeular Follieular Cysts of the Maxilla and Mandible, J. Oral Surg. 13: 102-107, 1955. 3. Folkins, J. A.: Multiple Dentigerous Cysts in a Child of Ten, J. Canad. Dent. A. 26: 140-145, 1959. 4. Kronfeld, R., and Boyle, P. E. (editors) : Histopathology of the Teeth and Their Surrounding Structures, ed. 3, Philadelphia, 1949, Lea & Febiger. 5. Pekarsky, R. L.: Dentigerous Cysts of the Jaw With Unerupted Teeth, ORAL BURG.,ORAL MED. & ORAL PATH. 3: 860-867, 1950. 6. Pizer, M. E.: Dentigerous Cyst of the Wall of the Maxillary Sinus, ORAL SU&G., OXAL MED. & ORAL PATH. 7: 1210-1211, 1954. 7. Scales, J. L., and Calhoun, N. R.: Bilateral Impacted Third and Supernumerary Molars Associated With a Dentigerous Cyst, Items Interest 74: 1121-1123, 1952. 8. Shafer, W. G., Hine, M. K., and Levy, B. M. : A Textbook of Oral Pathology, ed. 2, Philadelphia, 1963, W. B. Saunders Company. 9. Sharland, R. J.: Case of Multiple Dentigerous Cysts of the Mandible, Brit. D. J. 84: 35-36, 1948. 10. Sicher, Harry (editor) : Orban’s Oral Histology and Embryology, ed. 5, St. Louis, 1962, The C. V. Mosby Company. 11. Uhler, I. V.: Bilateral Dentigerous Cysts, J. Am. Dent. A. 37: 729-730, 1948.