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Choroiditis caused by a palatally impacted unerupted maxillary rudimentary supernumerary cuspid
Oral
Medicine
CHOROIDITIS CAUSED BY A PALATALLY IMPACTED MAXILLARY RUDIMENTARY SUPERNUMERARY Report
of a Case
ARCHER, B.S., D.D.S., MS.,*
W. HURY
UNERUPTED CUSPID
~ITTSKR~H,
.INI) lI~~~.\~~
I).l).S.,“”
S. FOX,
p.\.
A., a 42-year-old man, was admitted to the Bye and Ear Hospital on July 1, 1950, complaining of “blurred vision ’ * of the right eye. History.-Blurred vision began two weeks previously and increased ill severity over a three-day period. The patient received foreign protein and souls: t,ablets from his family physician prior to admission. This helped his vision slightly. One day prior to admission, he claimed he was able to see only the t,hird line of the eye chart, whereas he was able to detect the letters in tl\e eighth line two weeks previously. The patient had noticed a twit,ch in his right eye for about, a year but never had blurred vision before. He had no paitl, but the feeling of having a foreign body in his eye, as well as pressure in the eye, was present.
C.
Physical
Examination.-Physical
examination
was essentially
ltrgatiyt~.
Locnl Eye Emmcmination.-Right eye : conjuctiva, sclera, all normal: corma, clear ; anterior chamber, normal; pupils, dilated; metlia, clear; fundus, ner\‘c head, well outlined, yellow in color; vessels normal in size ant1 course, S~Ililll white exudate of choroid just above macula; macular reflex absent. l,ct’i- c>-C’. normal, no pain, no photophobia, no diplopia. Tensions of 17 mm. itt (1ac.h eye. (Normal, 15-25.) Vision: Right eye, 20/W): left eye, 20/20. Eal’s.--The patient other physical defects,
complained
of pnin arotmd thr
Laboratory Examination.-Complete red, 5,210,OOO; white, 8,500; hemoglobin,
lliagnosis:
blood
count
right showed
car an(l hatI the
IIO
following
10-C per cent.
Choroiditis.
Oral Examination.-Almost a complete complement of teeth was prrsrrrt. Some resorption of gingival soft The teeth were all in good state of repair. There were no gingival pockets nor tissues was noted which was physiologic. could pus be expressed. All teet,li reacted to the electric pulp tester. Radiographic Examination.--Radiographic examination revealed a rurliment,ary supernumerary cuspid in the right, cuspid area of the palat,e. *F'rOfe~~or
**Oral
of Oral Surgery, School of Dentistry, T7niversity Surgery Resident, Eye an<1 Ear Hospital. 861
of Pittsburgh.
:
862
W. HARRY
ARCHER
AND LIZONARD S. FOX
Hospital Course.-The day after admission the temperature remained normal. On July 5, the patient felt that his vision improved somewhat. The feeling of intense pressure and the foreign body sensation were still present. Operative Notes.-On July 6, under Pentothal and oxygen anesthesia, the face and mucous membrane were prepared; mouth prop was inserted; tongue suture was placed and oropharyngeal partition was inserted. A right anterior palatine and nasopalatine injection of 2 per cent procaine hydrochloride, l/10,000 Cobefrin was given. With a Bard-Parker No. 12 blade, the Iingual tissues were incised around the necks of the teeth beginning on the lingual of the upper right centr.al incisor and extending to the right second premolar. Incision was made in the interproximal space between the two maxillary central incisors and carried back along the center of the palate for about 11/z inches. The mucoperiosteum was reflected from the hard palate with a periosteal elevator. The bone overlying the rudimentary supernumerary cuspid tooth was removed with bone burrs, chisels, and mallet, in the following manner: With a bone burr, holes
Fig.
I.-Choroiditis
caused by a partially impacted unerupted numerary cuspid.
maxillary
rudimentary
super-
were drilled in the palatal bone 3 mm. apart around the crown of the rudimentary impacted tooth, being careful not to damage the roots of the adjacent teeth. By means of a chisel and mallet the drilled holes around the crown of the impacted tooth in the palatal bone were connected and the bone overlying the crown was removed. The size of the opening was enlarged by the use of the chisel so that the complete crown was seen. Then a groove was cut around the crown with cross-cut fissure burrs. Two apexo eIevators were then placed on both sides of the crown (one elevator on each side) and, with a double lifting action using the palatine bone as a fulcrum, the toot’h was removed from the socket. Crystalline sulfanilamide and Gelfoam were placed in the socket. Four The interrupted catgut sutures were used to fix the flap back in position. patient left the operating room in good condition. Diagnosis: central incisor.
Impacted
unerupted
Postoperative Notes.-Almost thetic, the patient
maxillary
rudimentary
supernumerary
immediately after reacting from the anesclaimed that his vision had improved greatly and that the
CIIOIWlDITIS
, .,. ,hI,, /
severe pressure in his eye was relieved. Visiou was tested and WiLS aS follOWS right eye, 20/40; left eye, 20/20. The vision continued to improve. On July 7. 1950, vision in the right eye was 20/30. Th(h paticlnt, was discharged on .Irlly !I, 1950.
Discussion Etiology of Nonspecific Choroiditk-111 some cases it is difficult, and ever\ Autointoxication front impossible to detect the cause of chronic choroiditis. septic foci such as pyorrhea, apical dental abscesses, infected t.onsils: sinusitis. and the toxemias has been blamed. Acute infec.tious diseases? rheumatism, gou\? anemia, chlorosis, and uncorrected errors of refraction are also alleged to pla\r a part in producing this disease. Treatment is directed toward locating and dealing with any focus of ilrfection such as teeth, tonsils, and sinuses. The elimination of toxic substnnct~s is promoted by giving plenty of fluids, hot baths, and antibiotics. Prognosis depends on the site of the lesion in relation to macula and the damage done to other intraocular structures such as the retina, vitreous, and lens. In the case reported here there was nothing specific? except the paiatally impacted unerupted rudimentary supernumerary cuspid. Pathology of Chronic Choroiditk-There are certain pathologic feat,urcAs common to all the clinical varieties of chronic choroiditis and others which art’ peculiar to the infecting organism and its manifestation in the tissues. Of the former features, vascular congestion, leukocytic infiltrat,ion, :uid edema may be localized or diffuse. In the localized or nodular variety the bloocl vessels are dilated, the stroma cells are rounded and have their processes rctracted. and the chromatophores are aggregated around nodules and show degenerative changes. The retinal pigment epithelium undergoes degenerat,ion, the rells b~on~~ edematous and swollen, some proliferate and become heaped up while othclrs pass into the subretinal space and break down. The retina becomes puckered and folded, and later masses of conncctivc tissue cells form in it and it becomes detached. The vit.reous shows opacit,ies. the lens becomes op.aque, the sclera is inflamed and later undergoes degenerat,ion and becomes thickened. There is optic atrophy and hyaline degeneration of 111e scar tissue in the choroid. Ossification and deposits of cholesterin crystals iirc late eve&s. The eyeball shrinks, intraocular tension fails, and vision is lost Summary The case reported here was not a chronic choroiditis. Hence it must, ire considered to be a choroiditis of unknown etiology possibly produced by the irrrpacted unerupted supernumerary rudimentary cuspid.
References Duke-Elder, Sir W. Stewart: Text Book of Ophthalmoloyv, I~omlon, 1922, Henry Kinrllton. Rerrins, Corrin: Eye and Its Diseases, Philadelphia, l!i:icit IV. 13. Saunders (~ompa~~~.
Medicine
CHOROIDITIS CAUSED BY A PALATALLY IMPACTED MAXILLARY RUDIMENTARY SUPERNUMERARY Report
of a Case
ARCHER, B.S., D.D.S., MS.,*
W. HURY
UNERUPTED CUSPID
~ITTSKR~H,
.INI) lI~~~.\~~
I).l).S.,“”
S. FOX,
p.\.
A., a 42-year-old man, was admitted to the Bye and Ear Hospital on July 1, 1950, complaining of “blurred vision ’ * of the right eye. History.-Blurred vision began two weeks previously and increased ill severity over a three-day period. The patient received foreign protein and souls: t,ablets from his family physician prior to admission. This helped his vision slightly. One day prior to admission, he claimed he was able to see only the t,hird line of the eye chart, whereas he was able to detect the letters in tl\e eighth line two weeks previously. The patient had noticed a twit,ch in his right eye for about, a year but never had blurred vision before. He had no paitl, but the feeling of having a foreign body in his eye, as well as pressure in the eye, was present.
C.
Physical
Examination.-Physical
examination
was essentially
ltrgatiyt~.
Locnl Eye Emmcmination.-Right eye : conjuctiva, sclera, all normal: corma, clear ; anterior chamber, normal; pupils, dilated; metlia, clear; fundus, ner\‘c head, well outlined, yellow in color; vessels normal in size ant1 course, S~Ililll white exudate of choroid just above macula; macular reflex absent. l,ct’i- c>-C’. normal, no pain, no photophobia, no diplopia. Tensions of 17 mm. itt (1ac.h eye. (Normal, 15-25.) Vision: Right eye, 20/W): left eye, 20/20. Eal’s.--The patient other physical defects,
complained
of pnin arotmd thr
Laboratory Examination.-Complete red, 5,210,OOO; white, 8,500; hemoglobin,
lliagnosis:
blood
count
right showed
car an(l hatI the
IIO
following
10-C per cent.
Choroiditis.
Oral Examination.-Almost a complete complement of teeth was prrsrrrt. Some resorption of gingival soft The teeth were all in good state of repair. There were no gingival pockets nor tissues was noted which was physiologic. could pus be expressed. All teet,li reacted to the electric pulp tester. Radiographic Examination.--Radiographic examination revealed a rurliment,ary supernumerary cuspid in the right, cuspid area of the palat,e. *F'rOfe~~or
**Oral
of Oral Surgery, School of Dentistry, T7niversity Surgery Resident, Eye an<1 Ear Hospital. 861
of Pittsburgh.
:
862
W. HARRY
ARCHER
AND LIZONARD S. FOX
Hospital Course.-The day after admission the temperature remained normal. On July 5, the patient felt that his vision improved somewhat. The feeling of intense pressure and the foreign body sensation were still present. Operative Notes.-On July 6, under Pentothal and oxygen anesthesia, the face and mucous membrane were prepared; mouth prop was inserted; tongue suture was placed and oropharyngeal partition was inserted. A right anterior palatine and nasopalatine injection of 2 per cent procaine hydrochloride, l/10,000 Cobefrin was given. With a Bard-Parker No. 12 blade, the Iingual tissues were incised around the necks of the teeth beginning on the lingual of the upper right centr.al incisor and extending to the right second premolar. Incision was made in the interproximal space between the two maxillary central incisors and carried back along the center of the palate for about 11/z inches. The mucoperiosteum was reflected from the hard palate with a periosteal elevator. The bone overlying the rudimentary supernumerary cuspid tooth was removed with bone burrs, chisels, and mallet, in the following manner: With a bone burr, holes
Fig.
I.-Choroiditis
caused by a partially impacted unerupted numerary cuspid.
maxillary
rudimentary
super-
were drilled in the palatal bone 3 mm. apart around the crown of the rudimentary impacted tooth, being careful not to damage the roots of the adjacent teeth. By means of a chisel and mallet the drilled holes around the crown of the impacted tooth in the palatal bone were connected and the bone overlying the crown was removed. The size of the opening was enlarged by the use of the chisel so that the complete crown was seen. Then a groove was cut around the crown with cross-cut fissure burrs. Two apexo eIevators were then placed on both sides of the crown (one elevator on each side) and, with a double lifting action using the palatine bone as a fulcrum, the toot’h was removed from the socket. Crystalline sulfanilamide and Gelfoam were placed in the socket. Four The interrupted catgut sutures were used to fix the flap back in position. patient left the operating room in good condition. Diagnosis: central incisor.
Impacted
unerupted
Postoperative Notes.-Almost thetic, the patient
maxillary
rudimentary
supernumerary
immediately after reacting from the anesclaimed that his vision had improved greatly and that the
CIIOIWlDITIS
, .,. ,hI,, /
severe pressure in his eye was relieved. Visiou was tested and WiLS aS follOWS right eye, 20/40; left eye, 20/20. The vision continued to improve. On July 7. 1950, vision in the right eye was 20/30. Th(h paticlnt, was discharged on .Irlly !I, 1950.
Discussion Etiology of Nonspecific Choroiditk-111 some cases it is difficult, and ever\ Autointoxication front impossible to detect the cause of chronic choroiditis. septic foci such as pyorrhea, apical dental abscesses, infected t.onsils: sinusitis. and the toxemias has been blamed. Acute infec.tious diseases? rheumatism, gou\? anemia, chlorosis, and uncorrected errors of refraction are also alleged to pla\r a part in producing this disease. Treatment is directed toward locating and dealing with any focus of ilrfection such as teeth, tonsils, and sinuses. The elimination of toxic substnnct~s is promoted by giving plenty of fluids, hot baths, and antibiotics. Prognosis depends on the site of the lesion in relation to macula and the damage done to other intraocular structures such as the retina, vitreous, and lens. In the case reported here there was nothing specific? except the paiatally impacted unerupted rudimentary supernumerary cuspid. Pathology of Chronic Choroiditk-There are certain pathologic feat,urcAs common to all the clinical varieties of chronic choroiditis and others which art’ peculiar to the infecting organism and its manifestation in the tissues. Of the former features, vascular congestion, leukocytic infiltrat,ion, :uid edema may be localized or diffuse. In the localized or nodular variety the bloocl vessels are dilated, the stroma cells are rounded and have their processes rctracted. and the chromatophores are aggregated around nodules and show degenerative changes. The retinal pigment epithelium undergoes degenerat,ion, the rells b~on~~ edematous and swollen, some proliferate and become heaped up while othclrs pass into the subretinal space and break down. The retina becomes puckered and folded, and later masses of conncctivc tissue cells form in it and it becomes detached. The vit.reous shows opacit,ies. the lens becomes op.aque, the sclera is inflamed and later undergoes degenerat,ion and becomes thickened. There is optic atrophy and hyaline degeneration of 111e scar tissue in the choroid. Ossification and deposits of cholesterin crystals iirc late eve&s. The eyeball shrinks, intraocular tension fails, and vision is lost Summary The case reported here was not a chronic choroiditis. Hence it must, ire considered to be a choroiditis of unknown etiology possibly produced by the irrrpacted unerupted supernumerary rudimentary cuspid.
References Duke-Elder, Sir W. Stewart: Text Book of Ophthalmoloyv, I~omlon, 1922, Henry Kinrllton. Rerrins, Corrin: Eye and Its Diseases, Philadelphia, l!i:icit IV. 13. Saunders (~ompa~~~.