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Cysts of the Jaw*
CYSTS OF THE JAW * By R. A. FENTO N, D.D .S., Iowa City, Iowa
H E object of this paper will be to discuss briefly the classification of cysts, their etiology, microscopic pathology and symptoms. In more detail, I shall discuss their relationship to surrounding tissues, the important factors determining the diag nosis, and the essentials of scientific treatment. I would bring to you the fact that it is not well to consider all cysts simple affairs, while admitting that many re quire simple operative procedures. A few may be extremely difficult to re move and almost defy complete removal without resection o f the mandible. Protect yourselves on diagnosis and prognosis and you will sometimes save considerable postoperative explanation when you discover that the cyst has recurred, or that you fail on the diag nosis and are dealing with a growth in place of a cyst. T h e operative procedure is simple for most cysts, if they are of a certain type, but one failure will offset fifty suc cessful operations, unless the operator has protected himself in diagnosis and prognosis, and has obtained all the sci entific data connected with the case. T w o cases were reported to our clinic. They were both recurrences of apparently multiocular cysts or ada
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*R ead before the A m erican Society o f O ral Surgeons and Exodontists, L ouisville, K y., Sept. 18 and 19, 192S. Jour. A .D . A., December, 1926
mantinomas. Operation had been per formed two to three years previously. One came in with a form er diagnosis of adamantinoma. T he tissue had been sectioned and diagnosed as such by a competent pathologist. In the second case, no tissue had been saved and no microscopic diagnosis made; hence, there was no aid in making the present diagnosis. T he history is a very im portant factor to the pathologist as well as to the clinician. T he roentgen-ray appearance o f both cases was very similar. T he location of the lesions was similar. T he gross findings at the operation were similar, yet the second case turned out to be osteitis fibrosis cystica (no epithelial tissue), while the first case was an adamantinoma. Was the second case a cyst, an admantinoma or osteitis fibrosis cystica, three years ago? Those data would have been very valuable to oper ator and pathologist at the present time as to both diagnosis and prognosis. Both operators failed, as perhaps I have. Tim e alone will tell; but one operator failed scientifically, while the other could just as well have operated before the days of microscope and pathologists. Don’t misunderstand me. I would not have laboratory tests and findings displace history and clinical findings, fo r I know that, as yet, there has been no laboratory test to take the place of 1724
Fenton— Cysts of the Jaw common sense. Yet, I do believe we should take advantage of all modern facilities in aiding us to a right diag nosis and prognosis. And even then we will sometimes make mistakes, but per haps we can reduce the percentage of our mistakes. You may have no pathologist where you are practicing, but that is no alibi, as tissues can be preserved in a solution of formaldehyd and a portion can be sent to a pathologist. Do not think I am a Pharasee or that I am high hatting you: I have prob ably had more grief than any of you because I have had the opportunity for much grief and I am giving you the benefit of my experience during the past ten years in hopes that you may avoid a few rough spots. I f you become too positive in statements to your patients, too sure of your knowledge, you are riding for a fall. Always leave some leeway. Alexander Pope says “ The mouse that trusts himself to one poor hole is not a mouse of any soul.” Neither would I have you vacillate and lose the confidence of your patients. Only don’t promise too much or assure the patient that he has just arrived at your office in time. I t is hardly neces sary to be so scientific or pseudo-scien tific as to deal with contaminated cultures or to show a cloudy test tube to the patient in tw enty-four hours to demonstrate that the teeth you extracted were badly infected. T h at is straight commercialism and better appreciated in the clothing busi ness than in a profession for service to the people. In our clinic, we observed a case which, at first thought, seemed a simple dentigerous cyst, but which, on further
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investigation, proved a dentigerous cyst plus a giant cell tumor. Another case that history and roent gen ray would lead one to believe was a root cyst or an inflammatory cyst fu r ther investigation proved to be a giant celled tumor. A third case, that by his tory, location and roentgen ray and by the nature of the material removed at operation seemed to be an adamanti noma or the third type of cyst, was osteitis fibrosa cystica. A solid type of adamantinoma that gave the clinical appearance of a carcinoma by the micro scope was diagnosed as an adamanti noma. Thus you see why I wish to stress complete examination. And while Caesar, in his Commentaries, says that men think largely what they wish to think, it is well to pick up all the data before thinking out loud to the patient. As to classification of cysts, the sim plest classification suits me best, as that comes within my understanding. This classification is according to origin. T he root cyst springs from epithelial cell rests in the peridental membrane. T hree forms of cysts or tumors are recognized as coming from the enamelforming organ: (1 ) the dentigerous or follicular cyst, and (2 ) the adamanti noma or multiocular cyst; and (3 ) the adamantinoma may produce enamel or convert adjoining fibroblasts into odon toblasts, which, in turn, will produce an adamantinoma. This classification is by Mallory. The root or inflammatory cyst springs from granulomas at the root ends o f devitalized teeth or teeth containing dead pulps, the center of the granuloma breaking down and becoming liquified and the cavity in the bone occupied, be ing lined by epithelium laid down on
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The Journal of the American Dental Association
fibrous tissue. As to the origin of the epithelium, it is generally supposed to come from epithelial cell rests in the peridental membrane. T he sequence of events in a root cyst is, then, (1 ) irritation from a devital ized tooth or dead pulp; (2 ) granulo matous liquefication of the center and (3 ) the formation of the cyst. Cysts usually grow in the direction from which they meet the least resist ance, and as they grow and exert pres sure on the bone, there is destruction of bone next the cyst wall, by the osteoclasts and, on the side of the bone furthest from the cyst wall, a laying down of new bone by the osteoblasts. This is truly new bone that is formed as proved by D r. Prentis and me, and not merely a calcification, as is some times supposed. T h e cyst fluid is usually straw col ored, sometimes darker, and often contains cholesterin crystals and old epithelial cells. T his fluid is sometimes gelatinous. Infrequently, this fluid may contain bacteria, either because the cyst has ruptured into the mouth or been contaminated by surgical procedure, or possibly of hematogenous origin. T he cyst wall consists of fibrous tis sue lined with epithelium, the thickness of this wall depending somewhat on whether the cyst communicates with the mouth or nose and the length of time this communication has been in effect. As to symptoms, these cysts develop slowly. In these early stages they usu ally produce no symptoms, unless they become infected, and usually are dis covered only by roentgen ray. Later, the symptoms that arise will depend on the structures involved, and on pain when nerve trunks are involved. Changes in contour of the jaws or face,
or both, and all the symptoms of an acute inflammation are present if the contents become infected. O ften, palpation gives the impression as of feeling parchment, almost a sen sation of crepitus, but not always, de pending on the thickness of bone over the area palpated. An important symptom is the obtain ing of cyst fluid by aspiration and its examination. This more than any other thing will protect you from a surprise party at operation. T he roentgen ray will show a defi nitely outlined cavity. On these symp toms, plus history, we make our diagnosis, and then, if puzzled at all by our findings at operation, we turn the material over to the pathologist. Cysts must be differentiated from empyema of the antrum, hydrops of the antrum, and growths, more frequently some type of sarcoma than carcinoma, owing to the fact that cysts usually de velop earlier than the carcinoma age. In regard to the relationships to sur rounding structures: nerve trunks and blood vessels are not destroyed by the cysts but are gradually pushed to one side until they may occupy abnormal positions. T he antrum is, in some cases, practically eliminated by the cyst press ing the antrum floor up almost to the orbital plate. T he true antrum remains much reduced in size but not involved. R EPO R T O F CASE
A m an, aged 33, had a discharge o f very fo u l pus at night, fro m the le ft side o f the nose. T h is had continued f o r the past two years, fo llo w in g an acute inflam m ation o f th at portion o f the face and m outh. Roentgen-ray exam ination o f the sinus showed that the le ft antrum was blurred. T ran sillu m i nation showed th at the le ft antrum was dark. Puncture and washings o f this region through the nose yielded a large am ount o f fo u l pus. Yet operation showed the true antrum pushed
Fenton— Cysts of the Jaw alm ost to the orbit and not involved, and a large ro o t cyst extending fro m the central to the second m olar, occupying most o f the n o r m al an tru m space. T h is cyst had become in fected and had form ed a sinus in the in ferio r meatus o f the nose, which explained the dis charge o f pus. T h e condition sim ulated empyem a o f the antrum .
It has been my observation that, while realizing that it is clearly possible for an antrum to become infected from an acutely infected cyst breaking into it, by far the most frequent cause of antrum involvement is the strong arm of the operator when removing the cyst, as often the cyst wall and antrum mucosa are almost in contact and this requires extreme care in removing the cyst wall and not tearing out the floor of the antrum. Treatm ent.— T here are various methods of treating these cysts, all of which are surgical. T he size and loca tion may influence the detail of treat ment. T he route of approach should practically always be from the buccal or labial side. It would especially con demn the opening of these cysts through the roof of the mouth as deformity there is not well tolerated. It may in terfere with speech and also require the wearing of a plate. T h e method most successful in our hands consists of the elevation of the soft tissue on the labial or buccal side, starting at either the gingiva or an incision higher up. T he removal of the labial or buccal plate, and the com plete enucleation of the sac in its entirety, followed, if there is any ques tion about the complete removal of the sac, by the application of phenol, later neutralized with alcohol. T hen the bony margins are so beveled as to allow partial collapse of the soft tissues. T he cavity is then packed with gauze mois tened with quaiacol and olive oil. Packs
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are changed every twenty-four hours, and gradually reduced in size, and, after the first two or three days, plain gauze or iodoform gauze is used. T he first pack may be placed in tightly so as to arrest possible hemorrhage. Future packs should be placed in the cavity lightly so as to stimulate rather than hinder the formation o f granulation tissue. I f the surface becomes epithelized over, and there is still much deformity, the epithelium is removed by chemical cautery and granulation again stimu lated. In our observation, we find much more regeneration of bone in the man dible than in the maxillae. W hile deformity can be largely eliminated in , the maxillae as well as the mandible, the material which eliminates it in the maxillae seems to be soft tissue to a greater degree than bone. Hence, without history and clinical findings, the roentgen ray alone might make a postoperative case appear as a preopera tive case. Another method of operation is the Partsch, which consists of remov ing the buccal or labial soft and hard tissue overlying the cyst, and also the buccal or labial portion of the cyst wall. T he operation is then completed by suturing the margin of the remaining sac to the mucoperiosteum. Recovery is rapid as there is merely a suture line to heal. T he epithelial lining of that portion of sac left in the cavity under goes a change so that it simulates the epithelial lining of the mouth. T he objection to this form of oper ation is that the deformity, being lined with epithelial tissue, remains to a large degree still a deformity. A third form of operation as described by Berger consists of the
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The Journal of the American Dental Association
enucleation of the sac, followed by the suturing of the mucoperiosteum back to the original position, either leaving the cavity filled with blood or a pack which can be removed at a point where a suture is omitted. T h e success of this operation would depend somewhat on the size of the cyst and hence the size of the blood clot, as a large clot would disintegrate long be fore granulation takes place. O r if a pack is used, in working through a small opening, there would be some cases in which the cavity would become epithelized and a second cyst would be formed. A fter asking some of the best oral surgeons in this country relative to this form of treatment, I found it con demned in cases of large cysts by all except one man, who admitted that, sometimes, it might result in a cure. This entire discussion has been given to root cysts; but what applies to root cysts will also apply to dentigerous or follic ular cysts, except as to origin and time of origin. T he dentigerous cysts de velop from the enamel-forming organ of an unerupted tooth or denticle. They usually form or start to form at a time near the normal period of eruption of that tooth. Hence, they are most fre quently found in youth, although we have operated on few older patients. W hen these later cases developed is a question. T h e symptoms are practically' the same as for a root cyst. T he treatment is the same except, in addition to the enucleation of the sac, the unerupted tooth or denticle is removed. One word of warning: we sometimes have a dentigerous cyst formed after the removal of an unerupted tooth
without the destruction of the tooth follicle. W e sometimes have multiple cysts in the mouth, usually o f the dentiger ous type. These should be differen tiated from a poly cystitis, a rare condition effecting the long bones of the body. Roentgen-ray examination of the long bones will aid; also, if the aspi rated contents contain old epithelial cells, polycystitis can be eliminated, as these cysts of long bones are not lined with epithelium. Dentigerous cysts occur most frequently in the cuspid and third molar region. T he third class of cysts are the mul tiocular or adamantinomas. Their source is either the enamel-forming organ or the epithelial-cell rests in the mandible. T heir location is usually at the angle of the mandible. They often involve the ramus of the jaw to the extent of the coronoid and condyloid processes. Clinically, there seem to be two types, an almost solid type and a cystic type, yet microscopically they are very much alike. They grow as branching masses of epithelial cells, some corresponding to the adamantoblasts, while others form the stellate reticulum or enamel pulp. Cysts form, owing to distension and coalescence of vacuoles lying between cells correspond ing to those of the enamel pulp. Other cysts occur in the connective tissue of the stroma as a result o f focal collec tions of fluids. This tumor or cyst usually appears in the young adults. T he adamantinoma grows slowly and does not metastasize. Its complete removal is often very difficult, and hence recurrence is not infrequent. A number of cases are reported in
Fenton— Cysts of the Jaw which resection of the mandible was found necessary completely to eradicate the growth. O ur experience thus far has consisted of the surgical removal of the growth, followed by actual cautery, if possible; if not, chemical cautery and then radium. My experience with radium makes me very much afraid. I know little about it, and I have seen some very bad pathologic fractures from radium burns. These growths are known by a multitude o f names: adamantinoma, multilocular cyst, epi thelial odontoma, cystic carcinoma, adenocarcinoma and cyst adenoma of the jaw. Complete removal is equally difficult, regardless of the name used. Do not be too positive regarding diagnosis until you have heard from the pathologist, as the growth may be an osteosarcoma or an osteitis fibrosa cystica, which is clinically and patho logically on the same etiologic basis as a giant-cell tumor of bone. T he third type arising from the enamel organ is the odontoma, a com bination often of a cyst and a hard growth. T he enamel organ produces an adamantinoma, and this sometimes produces enamel. More often, the ameloblasts convert adjoining fibro blasts into odontoblasts, which re sults in the formation of dentin masses or dentin and cementum masses, or a composite odontoma may result owing to the activity of both the ameloblasts and the odontoblasts. DISCUSSION J. P. H enakan, C leveland, O h io : Simple or radicular cyst occurs very freq u en tly and on that account is o f im portance. It form s as the result o f degeneration o f the fa tty elements o f a granulom a, and, in consequence,
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fluid is form ed, the epithelial lin in g expands and, as it grow s, it, according to Scudder, en croaches on the bone, w hich, because o f the pressure, is absorbed. These C5rsts are often fo u n d to be o f a large size in the a n terior p a rt o f the m axilla, because the bone is not so dense as in the m andible. Because there is little or no pain, these cysts grow to great size before their existence is detected. T hey are o ften discovered by the patient because the enlargem ent causes d e fo rm ity ; a t other times, because pain results fro m pressure, and, in other cases, because the cyst has become in fected and g reat pain results fro m bacterial irrita tio n . These cysts occur very often and attain a g reat size in the incisive region, espe cially the lateral incisor- area. T h is is be lieved to be because the bone fo rm atio n in th at area is especially lacking in density, be cause o f the line o f union between the prem ax illary and m axillary bones. T h e term “ dentigerous cyst” is one used ra th e r loosely. It was first used to describe a cyst developing fro m tooth structure, such as an unerupted tooth or an odontom a. L ately, the term has been applied to a ll cysts arising fo r any reason fro m or around a tooth. T h e “ fo llic u la r cyst” is an exam ple o f this. Clinically, it resembles a “ radicular cyst,” but it arises fro m the enlarged fo llicle o f an unerupted tooth. “ M u ltilo cu lar cysts” differs from “ unilocular cysts” chiefly because o f their line o f developm ent, which includes m any cells; whereas, the “ unilocular cyst” is de veloped in a single cell. T h e “ m ultilocular cyst” is o ften fo u n d w ith a g reat m any cells, a ll extrem ely sm all, g iving the cyst a very irre g u la r shape and m aking its eradication very difficult. T h e difference between a m a lig n a n t gro w th and a benign gro w th very o ften lies in the fa c t th at the fo rm e r is not lim ited by a m em brane. In these m ultilocu la r cysts, such as are o ften fo u n d in the alveolar process, especially o f the m axillae, it is alw ays wise to have a specimen exam ined by a pathologist. We have a ll seen these grow ths a t the apical region o f a tooth. A fte r discharging its fluids, the grow th lies in the cancellous tissue and it requires great perseverance to fo llo w its crablike ram ifica tions, w ithout destroying m ore bone structure than was intended. R eg ard in g the m ethod o f surgical treatm ent fo r these cysts, there has been considerable discussion. Lyons recom mends and practices the exposure o f the cyst th ro u g h a w indow , and enucleation, follow ed
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The Journal of the American Dental Association
by surgical dressing f o r a sufficient time. Partsch recommends the exposure o f the cyst by exposure to its extrem e m argins, then sectioning it there and su tu rin g the mucous m em brane. It is contended by the adherents o f the m ethod th at the cyst m em brane takes on the function o f the mucous mem brane. T hose w ho do not accept th a t theory state th at the m ethod results in the m aintenance o f a g re at' fossae, as w ell as the retention o f a pathologic m em brane. I have fo u n d this m em brane very thick in some cases, and while it w ould ad ap t the case to the perform ance o f the Partsch operation, I have lacked con fidence in their pow er o f reconstruction. X have follow ed the Lyons method. F rank B. H o w ery L ou isville, K y . : T he w hole trend o f our profession, and th at o f the medical profession today, is to w a rd m ore com plete diagnosis. As D r. Fenton says, if we are slipshod or inclined to w a rd snap diag nosis in these cases, we are only rid in g f o r a fa ll. T h is is most certainly true, not only in this p a rticu la r subject th at D r. Fenton has discussed, but also in all o f the phases o f our w ork. T h e great m ajo rity o f the recurrences in these cases are due to our fa ilu re in diag nosis ra th e r than to the treatm ent o f technic. I think that this is especially true in dealing w ith cysts, because o f the fa ct th a t we know th a t most o f these are sim ple affairs. D r. Fenton tells us that we should be thorough re g ard in g the history, clinical findings and lab o rato ry tests o f these cases. I wish espe cially to emphasize th at we should never take too m uch fo r granted but have o u r diagnosis m ade com plete by some com petent pathologist. I believe th a t D r. F en ton’s m ethod o f tre a t m ent o f complete rem oval, fro m the labial or buccal side, is by f a r the best. As to the use o f iodoform gauze in these cavities, we should never be in too m uch o f a h u rry in dismissing these patients but should p ro lo n g treatm ent until these cavities have practically filled in. It has been m y experience th at when some o f these patients are dismissed a little early, they come back w ith the cavities infected, and it has required a good deal of tim e and care to get them back to a norm al condition. J. P. W ahl, N e w Orleans, L a . : W ithout a proper diagnosis, we cannot even guess at the prognosis, and we should spare no means at a rriv in g a t such a diagnosis. T h e operation fo r the eradication o f most cysts m ig h t be
regarded by some as a simple procedure, but we often, as you a ll no doubt know by ex perience, encounter one th at gives us a great deal o f trouble w hen we try to rem ove it in its entirety 5 and very often, a fte r a year or tw o, the patient returns w ith a possible re currence o f the same condition, in a more ag g rav ated fo rm , or as a m alignancy. T hen we wish th a t we had spent m ore tim e on the case history, lab o rato ry tests and clinical find ings, which w ould not only have been o f m aterial im portance before operating, but w ould be o f inestim able value now . W e cannot rely solely on the roentgen-ray fo r a diagnosis, but in m ost cases the roentgen ray is o f g re at value in helping us to determine the extent o f the cyst, and its possible en croachm ent on im portant anatom ic parts. In D r. F enton’s classification o f cysts, the first classification, or th a t o f ro o t cysts, or inflam m atory cysts, w hich spring fro m the g ra n u lom a a t the root ends o f devitalized teeth, should be o f g reat im portance to every exodontist, and should impress on every one o f us the im portance o f a thorough curettem ent o f the granulom a a fte r the rem oval o f the tooth. I have seen and rem oved quite a few cysts in edentulous mouths, o r in places where teeth had been rem oved several years before, w hich, no doubt, had their orig in in the granulom a th at was le f t undisturbed when the tooth or teeth were rem oved. As D r. Fenton says, these cysts develop very slowly and are not noticed by the p atient u n til they either cause a slight deform ity, or cause pain by involving some nerve tru n k , or become in fected. It is fo rtu n ate f o r the operator and the p atient that, in the fo rm atio n o f these cysts, the nerve trunks and blood vessels are n o t destroyed, but are slow ly pushed aside. I can recall a very stubborn case that came under m y care a fe w years ago, in which the an tru m was alm ost entirely obliterated d u r ing the developm ent o f the cyst. I heartily agree w ith D r. Fenton in condem ning the opening o f these cysts through the ro o f o f the m outh: they should all be operated on from the labial o r buccal aspect, w here an opening o f sufficient size should be m ade to enable a complete rem oval o f the entire sac, and a slight fo ld in g in o f the tissue. P acking o f the w ound is essential. T h e th ird fo rm o f operation, as described by D r. B erger, has never m et w ith success in m y hands, in cysts o f any appreciable size, and I have long since discarded it. In the rem oval o f nonerupted
Fenton— Cysts of the Jaw not f u lly form ed th ird m olars, I have alw ays em phasized the im portance o f the rem oval o f the tooth follicle, and I am m ore than pleased to hear D r. Fenton sound a w ord o f w arn in g in this respect. I t is fo rtu n ate fo r the patient and the operato r th a t the th ird class o f cyst, the m u ltilocular, o r adam anti nom as, do not occur so freq u e n tly as the other tw o types, as they are m uch m ore difficult to remove, and cause m ore d efo rm ity to the patient. Theodor B lu m , N e w Y o rk C ity: The question o f differential diagnosis in cysts is much m ore im portant than we usually think. T h e one disease th a t we have to th in k o f is the one w hich D r. Fenton m entioned, namely, osteitis fibrosa cystica, or B arrie’s disease, B arrie hav in g described this condition. T h e roentgen shows how easily it can be mis taken fo r a m ultilocular cyst. It is not a tum or, sim ply an inflam m ation o f the bone w ith cyst form ations. F ro m the discussion you have heard o f cysts, one w ould believe that their etiology had been settled. R adic u lar cysts, we hear, originate fro m the epi thelial cells o f the peridental mem brane. T h is is one o f the theories, and as m uch re search w ork has yet to be done on the sub ject, it should not be accepted as final. W e have aspirated quite a larg e num ber o f cysts to determ ine w hether there was infection pres ent, and we fo u n d th at the vast m ajo rity o f cysts are not infected. I f infected, they have become so secondarily. W e m ust not fo rg e t th at cysts can also originate fro m tem p orary and supernum erary teeth. I am glad to hear D r. Fenton say th a t the antrum is never involved th ro u g h cysts in the m axillae except when an acute infection o f the cyst is the cause o f the breaking off o f the cyst contents into the antrum . I have only found one case, a case o f supernum erary teeth caus ing the cyst and the acute infection causing an involvem ent o f the antrum . T h ere seems to be some m isunderstanding re g ard in g the Partsch operation. T h e o rig in a to r o f this operation is not P artsch but H eath o f E n g land, the first to describe the operation fo r rem oval o f cysts. A ccording to Partsch, there is a conservative and a radical operation. T h e displacem ent o f the an tru m w hich is
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caused by these very large cysts, displacement even o f the nasal floor, is readily corrected as soon as pressure w ithin the cyst ceases. T h ro u g h ordinary breathing, speaking and m asticating, the tissues are stim ulated so th at the antrum regains its norm al shape, the nasal floor reaches its norm al position and the old cyst cavity flattens out. One cyst which develops aro u n d the th ird m olar in the m an dible is o ften overlooked, because so often we neglect tak in g e x tra -o ral plates o f the m andible. A ll we see on th a t film is the last m o lar tooth, not a larg e cystic involvm ent. F o r th a t reason and in cases sim ilar to the one D r. Fenton showed o f m any cysts in different parts o f the m outh, I alw ays try to impress on m y patient, even though there is only a cyst or a tu m o r on one side, th at all the teeth should be exam ined by roentgen ray, so th a t when I discharge m y patient, I know his m outh and teeth are in as good condition as possible and I have not overlooked any thing. In reg ard to the first case, which turned out to be a g ian t cell tu m o r: We do not study our patients carefully. T h e roentgen ray showed p ractically everything. W e m ust in terpret it. It is hum an, they say, to m ake mistakes. You w ill n ot find a dis tinct outline o f the w a ll o f the cyst. It a pparently seems to go over into the sound tissue, and th a t excludes the possibility o f a cyst. Sometimes you w ill find an outline which looks p ractically like the outline o f a cyst, and, in such case, m ake the mistake o f thin k in g it m ight be a cyst w hen it m ay even be an epiderm oid carcinom a. D r. F enton ( closing) : I wish to emphasize w hat D r. Blum has said re g ard in g the eti o logy o f cysts. T h e etiology given was th at w hich had been taken fro m texts. As he says, m uch w ork can be done before one can a r rive a t a definite conclusion as regards eti ology. H e spoke o f infection o f cysts. I have seen a fe w infected. T h ey showed their infection a fte r I aspirated. You can draw your own conclusions. I t was interesting to hear about hydrops o f the antrum . I had never seen th a t condition and was glad to get the inform ation. I am still a t sea, b u t I h a rd ly think that, a f te r the in fo rm atio n I have received, I w ill use the B erger operation on large cysts fo r some tim e.
H E object of this paper will be to discuss briefly the classification of cysts, their etiology, microscopic pathology and symptoms. In more detail, I shall discuss their relationship to surrounding tissues, the important factors determining the diag nosis, and the essentials of scientific treatment. I would bring to you the fact that it is not well to consider all cysts simple affairs, while admitting that many re quire simple operative procedures. A few may be extremely difficult to re move and almost defy complete removal without resection o f the mandible. Protect yourselves on diagnosis and prognosis and you will sometimes save considerable postoperative explanation when you discover that the cyst has recurred, or that you fail on the diag nosis and are dealing with a growth in place of a cyst. T h e operative procedure is simple for most cysts, if they are of a certain type, but one failure will offset fifty suc cessful operations, unless the operator has protected himself in diagnosis and prognosis, and has obtained all the sci entific data connected with the case. T w o cases were reported to our clinic. They were both recurrences of apparently multiocular cysts or ada
T
*R ead before the A m erican Society o f O ral Surgeons and Exodontists, L ouisville, K y., Sept. 18 and 19, 192S. Jour. A .D . A., December, 1926
mantinomas. Operation had been per formed two to three years previously. One came in with a form er diagnosis of adamantinoma. T he tissue had been sectioned and diagnosed as such by a competent pathologist. In the second case, no tissue had been saved and no microscopic diagnosis made; hence, there was no aid in making the present diagnosis. T he history is a very im portant factor to the pathologist as well as to the clinician. T he roentgen-ray appearance o f both cases was very similar. T he location of the lesions was similar. T he gross findings at the operation were similar, yet the second case turned out to be osteitis fibrosis cystica (no epithelial tissue), while the first case was an adamantinoma. Was the second case a cyst, an admantinoma or osteitis fibrosis cystica, three years ago? Those data would have been very valuable to oper ator and pathologist at the present time as to both diagnosis and prognosis. Both operators failed, as perhaps I have. Tim e alone will tell; but one operator failed scientifically, while the other could just as well have operated before the days of microscope and pathologists. Don’t misunderstand me. I would not have laboratory tests and findings displace history and clinical findings, fo r I know that, as yet, there has been no laboratory test to take the place of 1724
Fenton— Cysts of the Jaw common sense. Yet, I do believe we should take advantage of all modern facilities in aiding us to a right diag nosis and prognosis. And even then we will sometimes make mistakes, but per haps we can reduce the percentage of our mistakes. You may have no pathologist where you are practicing, but that is no alibi, as tissues can be preserved in a solution of formaldehyd and a portion can be sent to a pathologist. Do not think I am a Pharasee or that I am high hatting you: I have prob ably had more grief than any of you because I have had the opportunity for much grief and I am giving you the benefit of my experience during the past ten years in hopes that you may avoid a few rough spots. I f you become too positive in statements to your patients, too sure of your knowledge, you are riding for a fall. Always leave some leeway. Alexander Pope says “ The mouse that trusts himself to one poor hole is not a mouse of any soul.” Neither would I have you vacillate and lose the confidence of your patients. Only don’t promise too much or assure the patient that he has just arrived at your office in time. I t is hardly neces sary to be so scientific or pseudo-scien tific as to deal with contaminated cultures or to show a cloudy test tube to the patient in tw enty-four hours to demonstrate that the teeth you extracted were badly infected. T h at is straight commercialism and better appreciated in the clothing busi ness than in a profession for service to the people. In our clinic, we observed a case which, at first thought, seemed a simple dentigerous cyst, but which, on further
1725
investigation, proved a dentigerous cyst plus a giant cell tumor. Another case that history and roent gen ray would lead one to believe was a root cyst or an inflammatory cyst fu r ther investigation proved to be a giant celled tumor. A third case, that by his tory, location and roentgen ray and by the nature of the material removed at operation seemed to be an adamanti noma or the third type of cyst, was osteitis fibrosa cystica. A solid type of adamantinoma that gave the clinical appearance of a carcinoma by the micro scope was diagnosed as an adamanti noma. Thus you see why I wish to stress complete examination. And while Caesar, in his Commentaries, says that men think largely what they wish to think, it is well to pick up all the data before thinking out loud to the patient. As to classification of cysts, the sim plest classification suits me best, as that comes within my understanding. This classification is according to origin. T he root cyst springs from epithelial cell rests in the peridental membrane. T hree forms of cysts or tumors are recognized as coming from the enamelforming organ: (1 ) the dentigerous or follicular cyst, and (2 ) the adamanti noma or multiocular cyst; and (3 ) the adamantinoma may produce enamel or convert adjoining fibroblasts into odon toblasts, which, in turn, will produce an adamantinoma. This classification is by Mallory. The root or inflammatory cyst springs from granulomas at the root ends o f devitalized teeth or teeth containing dead pulps, the center of the granuloma breaking down and becoming liquified and the cavity in the bone occupied, be ing lined by epithelium laid down on
1726
The Journal of the American Dental Association
fibrous tissue. As to the origin of the epithelium, it is generally supposed to come from epithelial cell rests in the peridental membrane. T he sequence of events in a root cyst is, then, (1 ) irritation from a devital ized tooth or dead pulp; (2 ) granulo matous liquefication of the center and (3 ) the formation of the cyst. Cysts usually grow in the direction from which they meet the least resist ance, and as they grow and exert pres sure on the bone, there is destruction of bone next the cyst wall, by the osteoclasts and, on the side of the bone furthest from the cyst wall, a laying down of new bone by the osteoblasts. This is truly new bone that is formed as proved by D r. Prentis and me, and not merely a calcification, as is some times supposed. T h e cyst fluid is usually straw col ored, sometimes darker, and often contains cholesterin crystals and old epithelial cells. T his fluid is sometimes gelatinous. Infrequently, this fluid may contain bacteria, either because the cyst has ruptured into the mouth or been contaminated by surgical procedure, or possibly of hematogenous origin. T he cyst wall consists of fibrous tis sue lined with epithelium, the thickness of this wall depending somewhat on whether the cyst communicates with the mouth or nose and the length of time this communication has been in effect. As to symptoms, these cysts develop slowly. In these early stages they usu ally produce no symptoms, unless they become infected, and usually are dis covered only by roentgen ray. Later, the symptoms that arise will depend on the structures involved, and on pain when nerve trunks are involved. Changes in contour of the jaws or face,
or both, and all the symptoms of an acute inflammation are present if the contents become infected. O ften, palpation gives the impression as of feeling parchment, almost a sen sation of crepitus, but not always, de pending on the thickness of bone over the area palpated. An important symptom is the obtain ing of cyst fluid by aspiration and its examination. This more than any other thing will protect you from a surprise party at operation. T he roentgen ray will show a defi nitely outlined cavity. On these symp toms, plus history, we make our diagnosis, and then, if puzzled at all by our findings at operation, we turn the material over to the pathologist. Cysts must be differentiated from empyema of the antrum, hydrops of the antrum, and growths, more frequently some type of sarcoma than carcinoma, owing to the fact that cysts usually de velop earlier than the carcinoma age. In regard to the relationships to sur rounding structures: nerve trunks and blood vessels are not destroyed by the cysts but are gradually pushed to one side until they may occupy abnormal positions. T he antrum is, in some cases, practically eliminated by the cyst press ing the antrum floor up almost to the orbital plate. T he true antrum remains much reduced in size but not involved. R EPO R T O F CASE
A m an, aged 33, had a discharge o f very fo u l pus at night, fro m the le ft side o f the nose. T h is had continued f o r the past two years, fo llo w in g an acute inflam m ation o f th at portion o f the face and m outh. Roentgen-ray exam ination o f the sinus showed that the le ft antrum was blurred. T ran sillu m i nation showed th at the le ft antrum was dark. Puncture and washings o f this region through the nose yielded a large am ount o f fo u l pus. Yet operation showed the true antrum pushed
Fenton— Cysts of the Jaw alm ost to the orbit and not involved, and a large ro o t cyst extending fro m the central to the second m olar, occupying most o f the n o r m al an tru m space. T h is cyst had become in fected and had form ed a sinus in the in ferio r meatus o f the nose, which explained the dis charge o f pus. T h e condition sim ulated empyem a o f the antrum .
It has been my observation that, while realizing that it is clearly possible for an antrum to become infected from an acutely infected cyst breaking into it, by far the most frequent cause of antrum involvement is the strong arm of the operator when removing the cyst, as often the cyst wall and antrum mucosa are almost in contact and this requires extreme care in removing the cyst wall and not tearing out the floor of the antrum. Treatm ent.— T here are various methods of treating these cysts, all of which are surgical. T he size and loca tion may influence the detail of treat ment. T he route of approach should practically always be from the buccal or labial side. It would especially con demn the opening of these cysts through the roof of the mouth as deformity there is not well tolerated. It may in terfere with speech and also require the wearing of a plate. T h e method most successful in our hands consists of the elevation of the soft tissue on the labial or buccal side, starting at either the gingiva or an incision higher up. T he removal of the labial or buccal plate, and the com plete enucleation of the sac in its entirety, followed, if there is any ques tion about the complete removal of the sac, by the application of phenol, later neutralized with alcohol. T hen the bony margins are so beveled as to allow partial collapse of the soft tissues. T he cavity is then packed with gauze mois tened with quaiacol and olive oil. Packs
1727
are changed every twenty-four hours, and gradually reduced in size, and, after the first two or three days, plain gauze or iodoform gauze is used. T he first pack may be placed in tightly so as to arrest possible hemorrhage. Future packs should be placed in the cavity lightly so as to stimulate rather than hinder the formation o f granulation tissue. I f the surface becomes epithelized over, and there is still much deformity, the epithelium is removed by chemical cautery and granulation again stimu lated. In our observation, we find much more regeneration of bone in the man dible than in the maxillae. W hile deformity can be largely eliminated in , the maxillae as well as the mandible, the material which eliminates it in the maxillae seems to be soft tissue to a greater degree than bone. Hence, without history and clinical findings, the roentgen ray alone might make a postoperative case appear as a preopera tive case. Another method of operation is the Partsch, which consists of remov ing the buccal or labial soft and hard tissue overlying the cyst, and also the buccal or labial portion of the cyst wall. T he operation is then completed by suturing the margin of the remaining sac to the mucoperiosteum. Recovery is rapid as there is merely a suture line to heal. T he epithelial lining of that portion of sac left in the cavity under goes a change so that it simulates the epithelial lining of the mouth. T he objection to this form of oper ation is that the deformity, being lined with epithelial tissue, remains to a large degree still a deformity. A third form of operation as described by Berger consists of the
1728
The Journal of the American Dental Association
enucleation of the sac, followed by the suturing of the mucoperiosteum back to the original position, either leaving the cavity filled with blood or a pack which can be removed at a point where a suture is omitted. T h e success of this operation would depend somewhat on the size of the cyst and hence the size of the blood clot, as a large clot would disintegrate long be fore granulation takes place. O r if a pack is used, in working through a small opening, there would be some cases in which the cavity would become epithelized and a second cyst would be formed. A fter asking some of the best oral surgeons in this country relative to this form of treatment, I found it con demned in cases of large cysts by all except one man, who admitted that, sometimes, it might result in a cure. This entire discussion has been given to root cysts; but what applies to root cysts will also apply to dentigerous or follic ular cysts, except as to origin and time of origin. T he dentigerous cysts de velop from the enamel-forming organ of an unerupted tooth or denticle. They usually form or start to form at a time near the normal period of eruption of that tooth. Hence, they are most fre quently found in youth, although we have operated on few older patients. W hen these later cases developed is a question. T h e symptoms are practically' the same as for a root cyst. T he treatment is the same except, in addition to the enucleation of the sac, the unerupted tooth or denticle is removed. One word of warning: we sometimes have a dentigerous cyst formed after the removal of an unerupted tooth
without the destruction of the tooth follicle. W e sometimes have multiple cysts in the mouth, usually o f the dentiger ous type. These should be differen tiated from a poly cystitis, a rare condition effecting the long bones of the body. Roentgen-ray examination of the long bones will aid; also, if the aspi rated contents contain old epithelial cells, polycystitis can be eliminated, as these cysts of long bones are not lined with epithelium. Dentigerous cysts occur most frequently in the cuspid and third molar region. T he third class of cysts are the mul tiocular or adamantinomas. Their source is either the enamel-forming organ or the epithelial-cell rests in the mandible. T heir location is usually at the angle of the mandible. They often involve the ramus of the jaw to the extent of the coronoid and condyloid processes. Clinically, there seem to be two types, an almost solid type and a cystic type, yet microscopically they are very much alike. They grow as branching masses of epithelial cells, some corresponding to the adamantoblasts, while others form the stellate reticulum or enamel pulp. Cysts form, owing to distension and coalescence of vacuoles lying between cells correspond ing to those of the enamel pulp. Other cysts occur in the connective tissue of the stroma as a result o f focal collec tions of fluids. This tumor or cyst usually appears in the young adults. T he adamantinoma grows slowly and does not metastasize. Its complete removal is often very difficult, and hence recurrence is not infrequent. A number of cases are reported in
Fenton— Cysts of the Jaw which resection of the mandible was found necessary completely to eradicate the growth. O ur experience thus far has consisted of the surgical removal of the growth, followed by actual cautery, if possible; if not, chemical cautery and then radium. My experience with radium makes me very much afraid. I know little about it, and I have seen some very bad pathologic fractures from radium burns. These growths are known by a multitude o f names: adamantinoma, multilocular cyst, epi thelial odontoma, cystic carcinoma, adenocarcinoma and cyst adenoma of the jaw. Complete removal is equally difficult, regardless of the name used. Do not be too positive regarding diagnosis until you have heard from the pathologist, as the growth may be an osteosarcoma or an osteitis fibrosa cystica, which is clinically and patho logically on the same etiologic basis as a giant-cell tumor of bone. T he third type arising from the enamel organ is the odontoma, a com bination often of a cyst and a hard growth. T he enamel organ produces an adamantinoma, and this sometimes produces enamel. More often, the ameloblasts convert adjoining fibro blasts into odontoblasts, which re sults in the formation of dentin masses or dentin and cementum masses, or a composite odontoma may result owing to the activity of both the ameloblasts and the odontoblasts. DISCUSSION J. P. H enakan, C leveland, O h io : Simple or radicular cyst occurs very freq u en tly and on that account is o f im portance. It form s as the result o f degeneration o f the fa tty elements o f a granulom a, and, in consequence,
1729
fluid is form ed, the epithelial lin in g expands and, as it grow s, it, according to Scudder, en croaches on the bone, w hich, because o f the pressure, is absorbed. These C5rsts are often fo u n d to be o f a large size in the a n terior p a rt o f the m axilla, because the bone is not so dense as in the m andible. Because there is little or no pain, these cysts grow to great size before their existence is detected. T hey are o ften discovered by the patient because the enlargem ent causes d e fo rm ity ; a t other times, because pain results fro m pressure, and, in other cases, because the cyst has become in fected and g reat pain results fro m bacterial irrita tio n . These cysts occur very often and attain a g reat size in the incisive region, espe cially the lateral incisor- area. T h is is be lieved to be because the bone fo rm atio n in th at area is especially lacking in density, be cause o f the line o f union between the prem ax illary and m axillary bones. T h e term “ dentigerous cyst” is one used ra th e r loosely. It was first used to describe a cyst developing fro m tooth structure, such as an unerupted tooth or an odontom a. L ately, the term has been applied to a ll cysts arising fo r any reason fro m or around a tooth. T h e “ fo llic u la r cyst” is an exam ple o f this. Clinically, it resembles a “ radicular cyst,” but it arises fro m the enlarged fo llicle o f an unerupted tooth. “ M u ltilo cu lar cysts” differs from “ unilocular cysts” chiefly because o f their line o f developm ent, which includes m any cells; whereas, the “ unilocular cyst” is de veloped in a single cell. T h e “ m ultilocular cyst” is o ften fo u n d w ith a g reat m any cells, a ll extrem ely sm all, g iving the cyst a very irre g u la r shape and m aking its eradication very difficult. T h e difference between a m a lig n a n t gro w th and a benign gro w th very o ften lies in the fa c t th at the fo rm e r is not lim ited by a m em brane. In these m ultilocu la r cysts, such as are o ften fo u n d in the alveolar process, especially o f the m axillae, it is alw ays wise to have a specimen exam ined by a pathologist. We have a ll seen these grow ths a t the apical region o f a tooth. A fte r discharging its fluids, the grow th lies in the cancellous tissue and it requires great perseverance to fo llo w its crablike ram ifica tions, w ithout destroying m ore bone structure than was intended. R eg ard in g the m ethod o f surgical treatm ent fo r these cysts, there has been considerable discussion. Lyons recom mends and practices the exposure o f the cyst th ro u g h a w indow , and enucleation, follow ed
1730
The Journal of the American Dental Association
by surgical dressing f o r a sufficient time. Partsch recommends the exposure o f the cyst by exposure to its extrem e m argins, then sectioning it there and su tu rin g the mucous m em brane. It is contended by the adherents o f the m ethod th at the cyst m em brane takes on the function o f the mucous mem brane. T hose w ho do not accept th a t theory state th at the m ethod results in the m aintenance o f a g re at' fossae, as w ell as the retention o f a pathologic m em brane. I have fo u n d this m em brane very thick in some cases, and while it w ould ad ap t the case to the perform ance o f the Partsch operation, I have lacked con fidence in their pow er o f reconstruction. X have follow ed the Lyons method. F rank B. H o w ery L ou isville, K y . : T he w hole trend o f our profession, and th at o f the medical profession today, is to w a rd m ore com plete diagnosis. As D r. Fenton says, if we are slipshod or inclined to w a rd snap diag nosis in these cases, we are only rid in g f o r a fa ll. T h is is most certainly true, not only in this p a rticu la r subject th at D r. Fenton has discussed, but also in all o f the phases o f our w ork. T h e great m ajo rity o f the recurrences in these cases are due to our fa ilu re in diag nosis ra th e r than to the treatm ent o f technic. I think that this is especially true in dealing w ith cysts, because o f the fa ct th a t we know th a t most o f these are sim ple affairs. D r. Fenton tells us that we should be thorough re g ard in g the history, clinical findings and lab o rato ry tests o f these cases. I wish espe cially to emphasize th at we should never take too m uch fo r granted but have o u r diagnosis m ade com plete by some com petent pathologist. I believe th a t D r. F en ton’s m ethod o f tre a t m ent o f complete rem oval, fro m the labial or buccal side, is by f a r the best. As to the use o f iodoform gauze in these cavities, we should never be in too m uch o f a h u rry in dismissing these patients but should p ro lo n g treatm ent until these cavities have practically filled in. It has been m y experience th at when some o f these patients are dismissed a little early, they come back w ith the cavities infected, and it has required a good deal of tim e and care to get them back to a norm al condition. J. P. W ahl, N e w Orleans, L a . : W ithout a proper diagnosis, we cannot even guess at the prognosis, and we should spare no means at a rriv in g a t such a diagnosis. T h e operation fo r the eradication o f most cysts m ig h t be
regarded by some as a simple procedure, but we often, as you a ll no doubt know by ex perience, encounter one th at gives us a great deal o f trouble w hen we try to rem ove it in its entirety 5 and very often, a fte r a year or tw o, the patient returns w ith a possible re currence o f the same condition, in a more ag g rav ated fo rm , or as a m alignancy. T hen we wish th a t we had spent m ore tim e on the case history, lab o rato ry tests and clinical find ings, which w ould not only have been o f m aterial im portance before operating, but w ould be o f inestim able value now . W e cannot rely solely on the roentgen-ray fo r a diagnosis, but in m ost cases the roentgen ray is o f g re at value in helping us to determine the extent o f the cyst, and its possible en croachm ent on im portant anatom ic parts. In D r. F enton’s classification o f cysts, the first classification, or th a t o f ro o t cysts, or inflam m atory cysts, w hich spring fro m the g ra n u lom a a t the root ends o f devitalized teeth, should be o f g reat im portance to every exodontist, and should impress on every one o f us the im portance o f a thorough curettem ent o f the granulom a a fte r the rem oval o f the tooth. I have seen and rem oved quite a few cysts in edentulous mouths, o r in places where teeth had been rem oved several years before, w hich, no doubt, had their orig in in the granulom a th at was le f t undisturbed when the tooth or teeth were rem oved. As D r. Fenton says, these cysts develop very slowly and are not noticed by the p atient u n til they either cause a slight deform ity, or cause pain by involving some nerve tru n k , or become in fected. It is fo rtu n ate f o r the operator and the p atient that, in the fo rm atio n o f these cysts, the nerve trunks and blood vessels are n o t destroyed, but are slow ly pushed aside. I can recall a very stubborn case that came under m y care a fe w years ago, in which the an tru m was alm ost entirely obliterated d u r ing the developm ent o f the cyst. I heartily agree w ith D r. Fenton in condem ning the opening o f these cysts through the ro o f o f the m outh: they should all be operated on from the labial o r buccal aspect, w here an opening o f sufficient size should be m ade to enable a complete rem oval o f the entire sac, and a slight fo ld in g in o f the tissue. P acking o f the w ound is essential. T h e th ird fo rm o f operation, as described by D r. B erger, has never m et w ith success in m y hands, in cysts o f any appreciable size, and I have long since discarded it. In the rem oval o f nonerupted
Fenton— Cysts of the Jaw not f u lly form ed th ird m olars, I have alw ays em phasized the im portance o f the rem oval o f the tooth follicle, and I am m ore than pleased to hear D r. Fenton sound a w ord o f w arn in g in this respect. I t is fo rtu n ate fo r the patient and the operato r th a t the th ird class o f cyst, the m u ltilocular, o r adam anti nom as, do not occur so freq u e n tly as the other tw o types, as they are m uch m ore difficult to remove, and cause m ore d efo rm ity to the patient. Theodor B lu m , N e w Y o rk C ity: The question o f differential diagnosis in cysts is much m ore im portant than we usually think. T h e one disease th a t we have to th in k o f is the one w hich D r. Fenton m entioned, namely, osteitis fibrosa cystica, or B arrie’s disease, B arrie hav in g described this condition. T h e roentgen shows how easily it can be mis taken fo r a m ultilocular cyst. It is not a tum or, sim ply an inflam m ation o f the bone w ith cyst form ations. F ro m the discussion you have heard o f cysts, one w ould believe that their etiology had been settled. R adic u lar cysts, we hear, originate fro m the epi thelial cells o f the peridental mem brane. T h is is one o f the theories, and as m uch re search w ork has yet to be done on the sub ject, it should not be accepted as final. W e have aspirated quite a larg e num ber o f cysts to determ ine w hether there was infection pres ent, and we fo u n d th at the vast m ajo rity o f cysts are not infected. I f infected, they have become so secondarily. W e m ust not fo rg e t th at cysts can also originate fro m tem p orary and supernum erary teeth. I am glad to hear D r. Fenton say th a t the antrum is never involved th ro u g h cysts in the m axillae except when an acute infection o f the cyst is the cause o f the breaking off o f the cyst contents into the antrum . I have only found one case, a case o f supernum erary teeth caus ing the cyst and the acute infection causing an involvem ent o f the antrum . T h ere seems to be some m isunderstanding re g ard in g the Partsch operation. T h e o rig in a to r o f this operation is not P artsch but H eath o f E n g land, the first to describe the operation fo r rem oval o f cysts. A ccording to Partsch, there is a conservative and a radical operation. T h e displacem ent o f the an tru m w hich is
1731
caused by these very large cysts, displacement even o f the nasal floor, is readily corrected as soon as pressure w ithin the cyst ceases. T h ro u g h ordinary breathing, speaking and m asticating, the tissues are stim ulated so th at the antrum regains its norm al shape, the nasal floor reaches its norm al position and the old cyst cavity flattens out. One cyst which develops aro u n d the th ird m olar in the m an dible is o ften overlooked, because so often we neglect tak in g e x tra -o ral plates o f the m andible. A ll we see on th a t film is the last m o lar tooth, not a larg e cystic involvm ent. F o r th a t reason and in cases sim ilar to the one D r. Fenton showed o f m any cysts in different parts o f the m outh, I alw ays try to impress on m y patient, even though there is only a cyst or a tu m o r on one side, th at all the teeth should be exam ined by roentgen ray, so th a t when I discharge m y patient, I know his m outh and teeth are in as good condition as possible and I have not overlooked any thing. In reg ard to the first case, which turned out to be a g ian t cell tu m o r: We do not study our patients carefully. T h e roentgen ray showed p ractically everything. W e m ust in terpret it. It is hum an, they say, to m ake mistakes. You w ill n ot find a dis tinct outline o f the w a ll o f the cyst. It a pparently seems to go over into the sound tissue, and th a t excludes the possibility o f a cyst. Sometimes you w ill find an outline which looks p ractically like the outline o f a cyst, and, in such case, m ake the mistake o f thin k in g it m ight be a cyst w hen it m ay even be an epiderm oid carcinom a. D r. F enton ( closing) : I wish to emphasize w hat D r. Blum has said re g ard in g the eti o logy o f cysts. T h e etiology given was th at w hich had been taken fro m texts. As he says, m uch w ork can be done before one can a r rive a t a definite conclusion as regards eti ology. H e spoke o f infection o f cysts. I have seen a fe w infected. T h ey showed their infection a fte r I aspirated. You can draw your own conclusions. I t was interesting to hear about hydrops o f the antrum . I had never seen th a t condition and was glad to get the inform ation. I am still a t sea, b u t I h a rd ly think that, a f te r the in fo rm atio n I have received, I w ill use the B erger operation on large cysts fo r some tim e.