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Dentigerous Dermoid Cyst of the Ovary Containing a Portion of a Mandible
DENTIGEROUS DERMOID CYST OF THE OVARY CONTAINING A PORTION OF A MANDIBLE By D a v id F. H e r o n , D .D . S., D etroit, M ich. E R M O ID cysts containing teeth have frequently been reported in the medical and dental literature. The one reported here is, I believe, un usual in that it contained a well-formed portion of a mandible with several teeth erupting in their proper positions, as well as an underdeveloped portion of the ascending ramus.
D
r e po r t o f c a se
Mrs. C . M ., aged 32, six months pregnant, came to the hospital D ecem ber because of upper
abdominal
months’ duration.
A
18,
pain
1940,
of
two
hard, irregular mass
could be palpated to the left of the midline in the upper abdominal quadrant. retrograde
pyelogram
revealed
a
A
left
calcified
area, 2 inches by \ inch, in the region of the left kidney, and
roentgenographic
ex
amination showed this to be a dermoid cyst of the left ovary. A s a tumor was interfering with the progress of the pregnancy, an ab dominal
operation was perform ed on D e
cember 20, b y Ira G . Downer, to remove the growth, w hich proved to be a thin-walled ovoid cyst, measuring 11 cm. and 8.5 cm. in m axim um diameter and weighing 285 gm. The
cyst
contained
hair
and
sebaceous
material and, attached to its inner surface, a piece
of bone, approxim ately 7
cm.
in
length, having the shape and contour of one side of a mandible, as shown in the illustra tion.
A ttach ed to this bone was a spongy
mass, 3.5 cm. in diameter, containing hair. In proper position at the symphysis of the mandible
were
two
norm ally
fully erupted central incisors.
shaped
and
A d jacen t to
the incisors and also in normal position was From the Department Alexander Blain Hospital.
of
Oral
Jo u r. A .D .A ., V o l. 28, O ctober 1941
Surgery,
a partially erupted cuspid.
A t the opposite
end of the jaw bone was an ascending bony structure representing a rudimentary ramus. Here, another tooth was found loosely im planted
in
a socket.
Two
well-developed
molar teeth were also loosely attached to the posterior aspect of the mandible, and one of them was further attached to the inner lining of the cyst.
Dermoid cysts constitute about 10 per cent of all ovarian tumors, and, accord ing to Ewing,1 approximately half their number contain teeth and rudiments of bone. O f ninety-one dermoid cysts ob served in seventy-nine patients by Glass and Rosenthal,2 hair and sebaceous ma terial were found in eighty-one; teeth in eighteen, bones in thirteen and teeth and bones in eight. Some observers believe that embryonic tooth follicles are pres ent in all dermoid cysts. An interesting observation is that deciduous teeth tend to develop in cyst walls, while permanent teeth develop in an osseous matrix. Der moid cysts containing from one to sev eral hundred rudimentary teeth have been reported. These teeth may be found firmly implanted in sockets of rudimentary maxillae, lying free in the cyst cavity or more often embedded in the cyst wall. The teeth found have usually been incisors or molars. Occa sionally, a very rudimentary mandible with the coronoid process is seen. To be classed as a dermoid cyst, a cystic tumor must contain elements found in the dermis, such as sweat and sebaceous glands, hair, nails or epidermal tissue. Dermoid cysts may be found in various parts of the body. They have 1624
H
eron—
D
e n t ig e r o u s
been found inside the skull and about the neck and postanal region, but have a predilection for the ovary. Those occur ring in the ovary often have a tendency to perforate adjacent viscera. In one instance in which an ovarian dermoid cyst perforated the urinary bladder, teeth were removed from the bladder.3 Single, well-formed teeth have occasionally been found in dermoid cysts of the pelvic region. Microscopically, most of the tissues found in a dermoid cyst are adult in type, although deciduous teeth and tooth follicles have been reported. Hair, usu ally of a different color from that of the scalp hair of the patient, sebaceous material, sweat glands of the skin, por tions of salivary glands, thyroid tissue, bone and cartilage are frequently found. Portions of digits, intestine, brain, eyes, nerve ganglia, bone, bronchi and muscle have also been identified. Almost every known structure has been found within these dermoid cysts except the reproduc tive glands. These neoplasms completely involve the structures of the ovary or leave rem nants of the gland on one side of the tumor. The capsule is usually thin, gray ish or whitish and well-vascularized, and, in one portion of the wall, there is almost invariably a thickened area or “ head” from which spring bundles of hair. Un der its epithelial covering may be found the various tissues of a mature type which make up the characteristic con stituents of the dermoid cyst. These tumors are a cystic form and represent a one-sided development of teratoma. In contradistinction to most teratomas of the ovary, the dermoid cyst is benign. There is still no unanimity of opinion as to the histogenesis of dermoid cysts. They are held to be congenital and have often been found in young children, but are usually discovered during the repro ductive years. They are usually singu lar, but may be bilateral and multiple.
D
e r m o id
C
yst
1625
They vary in size, seldom exceeding the size of a cocoanut. Some authorities con tend that the dermoid cyst should be considered a twin, belonging to the same generation as the patient in whose ovary it develops. Wood4 points out logically that such a tumor must arise from a cell which is totipotent; that is, contains within itself the capacity of almost all types of tissue. This means that the cell must have been left in the ovary or formed in it at an early stage of develop ment. There are three principal theories explaining these tumors: The older and now abandoned theory was that polar bodies, after they are set free, are
D erm oid cyst of le ft ovary containing hair, fa tty m aterial, teeth and bone representing on e-half of a well-form ed m andible and under developed ascending ramus.
capable of further development. Another view, still held by some, is that unused blastomeres of high potency are left in the ovary during the course of its for mation. If, for some reason, the normal development of the primary blastoderm is interfered with, each blastomere may give rise to a small embryo or complex dermoid cyst. The present view, con curred in by both Ewing and Wood, is that these complex tumors and the solid teratomata of the ovary are derived from ova which undergo parthenogenetic
1626
T
he
J
ournal of th e
A m e r ic a n D
stimulus to development, and, as a re sult of that development, form a rudi mentary fetus. This is referred to by Ewing as “spontaneous growth of the unfertilized ovum.” As has been pointed out, ovarian dermoid cysts containing embryonic structures should occasion no surprise since the ovary is in reality an embryo factory, and, given the necessary stimulus, certain elements will start grow ing. Until more is learned concerning these embryomata, however, any discus sion of their origin must of necessity be purely speculative.
ental
A s s o c ia t io n b ib l io g r a p h y
1. E w i n g , J a m e s : Neoplastic Disease. Ed. 3. Philadelphia: W. B. Saunders Co., pp. 635-
666 . 2. G l a s s , M ., and R o s e n t h a l , A. H .: Study of Dermoid Cysts with Suggestion as to Use of X -ray in Diagnosis. Am.. J. Obst. & Gynec., 33:813-820, M a y 1937. 3. E w e l l , G. H. : Dermoid Cyst of Ovary Perforating into Urinary Bladder with Pro fuse Hematuria. Am. ]. Surg., 19:502-504, M arch 1933. 4. W o o d , F. C .: Tum ors; in Nelson’ s Loose Leaf Surgery. Vol. 11. N ew York: Thomas Nelson & Sons, 1937, pp. 116 -119 . 2201 Jefferson Avenue East.
SECONDARY DENTIN FORMATION IN THE DECIDUOUS TEETH By
R a lp h
L.
I r e la n d ,
B.S., D.D.S., Lincoln, Nebr.
T has been a matter of conjecture as to whether the deciduous teeth pos sess the ability to form secondary dentin in response to various external stimuli. Noyes, Schour and Noyes say, “The formation of secondary dentin in response to abrasion or caries, the ease with which the deciduous teeth abrade, and their high incidence of caries, pre sent problems necessitating further re search.” 1 Churchill, in his book “Human Odon tography and Histology” says, “The pulp tissue of the deciduous teeth does not, as a rule, react with the formation of adventitious dentin to external stimuli. Persisting elements may constitute an ex ception.” 2 Adventitious dentin is the
I
From the Department of Children’s D en tistry, University of Nebraska, College of Dentistry. Read before the Section on Children’s D en tistry and Oral Hygiene at the Eighty-Second Annual M eeting of the American Dental Asso ciation, Cleveland, Ohio, September 10, 1940.
Jo u r . A .D .A ., V o l. 28 , O cto ber 1941
term used by Churchill instead of sec ondary dentin. Bunting and Hill say, “Deciduous teeth also seem to be almost wholly lacking in the ability to form secondary dentin in response to injury. In them, it would appear that the physiologic tendency is toward resorption of dentin under stimu lation rather than the building of new structures.” 3 In the permanent teeth, secondary den tin is formed in response to various stimuli, such as caries, abrasion, opera tive procedures and chemical and thermal irritation. When the irritation is excessive, secondary dentin is formed much more rapidly and is more irregular in structure. If the irritation is mild, secondary dentin is deposited more slowly and its structure more closely re sembles that of primary dentin. In sound permanent teeth, secondary dentin is also formed intermittently throughout the life of the teeth. The theory is also
D
r e po r t o f c a se
Mrs. C . M ., aged 32, six months pregnant, came to the hospital D ecem ber because of upper
abdominal
months’ duration.
A
18,
pain
1940,
of
two
hard, irregular mass
could be palpated to the left of the midline in the upper abdominal quadrant. retrograde
pyelogram
revealed
a
A
left
calcified
area, 2 inches by \ inch, in the region of the left kidney, and
roentgenographic
ex
amination showed this to be a dermoid cyst of the left ovary. A s a tumor was interfering with the progress of the pregnancy, an ab dominal
operation was perform ed on D e
cember 20, b y Ira G . Downer, to remove the growth, w hich proved to be a thin-walled ovoid cyst, measuring 11 cm. and 8.5 cm. in m axim um diameter and weighing 285 gm. The
cyst
contained
hair
and
sebaceous
material and, attached to its inner surface, a piece
of bone, approxim ately 7
cm.
in
length, having the shape and contour of one side of a mandible, as shown in the illustra tion.
A ttach ed to this bone was a spongy
mass, 3.5 cm. in diameter, containing hair. In proper position at the symphysis of the mandible
were
two
norm ally
fully erupted central incisors.
shaped
and
A d jacen t to
the incisors and also in normal position was From the Department Alexander Blain Hospital.
of
Oral
Jo u r. A .D .A ., V o l. 28, O ctober 1941
Surgery,
a partially erupted cuspid.
A t the opposite
end of the jaw bone was an ascending bony structure representing a rudimentary ramus. Here, another tooth was found loosely im planted
in
a socket.
Two
well-developed
molar teeth were also loosely attached to the posterior aspect of the mandible, and one of them was further attached to the inner lining of the cyst.
Dermoid cysts constitute about 10 per cent of all ovarian tumors, and, accord ing to Ewing,1 approximately half their number contain teeth and rudiments of bone. O f ninety-one dermoid cysts ob served in seventy-nine patients by Glass and Rosenthal,2 hair and sebaceous ma terial were found in eighty-one; teeth in eighteen, bones in thirteen and teeth and bones in eight. Some observers believe that embryonic tooth follicles are pres ent in all dermoid cysts. An interesting observation is that deciduous teeth tend to develop in cyst walls, while permanent teeth develop in an osseous matrix. Der moid cysts containing from one to sev eral hundred rudimentary teeth have been reported. These teeth may be found firmly implanted in sockets of rudimentary maxillae, lying free in the cyst cavity or more often embedded in the cyst wall. The teeth found have usually been incisors or molars. Occa sionally, a very rudimentary mandible with the coronoid process is seen. To be classed as a dermoid cyst, a cystic tumor must contain elements found in the dermis, such as sweat and sebaceous glands, hair, nails or epidermal tissue. Dermoid cysts may be found in various parts of the body. They have 1624
H
eron—
D
e n t ig e r o u s
been found inside the skull and about the neck and postanal region, but have a predilection for the ovary. Those occur ring in the ovary often have a tendency to perforate adjacent viscera. In one instance in which an ovarian dermoid cyst perforated the urinary bladder, teeth were removed from the bladder.3 Single, well-formed teeth have occasionally been found in dermoid cysts of the pelvic region. Microscopically, most of the tissues found in a dermoid cyst are adult in type, although deciduous teeth and tooth follicles have been reported. Hair, usu ally of a different color from that of the scalp hair of the patient, sebaceous material, sweat glands of the skin, por tions of salivary glands, thyroid tissue, bone and cartilage are frequently found. Portions of digits, intestine, brain, eyes, nerve ganglia, bone, bronchi and muscle have also been identified. Almost every known structure has been found within these dermoid cysts except the reproduc tive glands. These neoplasms completely involve the structures of the ovary or leave rem nants of the gland on one side of the tumor. The capsule is usually thin, gray ish or whitish and well-vascularized, and, in one portion of the wall, there is almost invariably a thickened area or “ head” from which spring bundles of hair. Un der its epithelial covering may be found the various tissues of a mature type which make up the characteristic con stituents of the dermoid cyst. These tumors are a cystic form and represent a one-sided development of teratoma. In contradistinction to most teratomas of the ovary, the dermoid cyst is benign. There is still no unanimity of opinion as to the histogenesis of dermoid cysts. They are held to be congenital and have often been found in young children, but are usually discovered during the repro ductive years. They are usually singu lar, but may be bilateral and multiple.
D
e r m o id
C
yst
1625
They vary in size, seldom exceeding the size of a cocoanut. Some authorities con tend that the dermoid cyst should be considered a twin, belonging to the same generation as the patient in whose ovary it develops. Wood4 points out logically that such a tumor must arise from a cell which is totipotent; that is, contains within itself the capacity of almost all types of tissue. This means that the cell must have been left in the ovary or formed in it at an early stage of develop ment. There are three principal theories explaining these tumors: The older and now abandoned theory was that polar bodies, after they are set free, are
D erm oid cyst of le ft ovary containing hair, fa tty m aterial, teeth and bone representing on e-half of a well-form ed m andible and under developed ascending ramus.
capable of further development. Another view, still held by some, is that unused blastomeres of high potency are left in the ovary during the course of its for mation. If, for some reason, the normal development of the primary blastoderm is interfered with, each blastomere may give rise to a small embryo or complex dermoid cyst. The present view, con curred in by both Ewing and Wood, is that these complex tumors and the solid teratomata of the ovary are derived from ova which undergo parthenogenetic
1626
T
he
J
ournal of th e
A m e r ic a n D
stimulus to development, and, as a re sult of that development, form a rudi mentary fetus. This is referred to by Ewing as “spontaneous growth of the unfertilized ovum.” As has been pointed out, ovarian dermoid cysts containing embryonic structures should occasion no surprise since the ovary is in reality an embryo factory, and, given the necessary stimulus, certain elements will start grow ing. Until more is learned concerning these embryomata, however, any discus sion of their origin must of necessity be purely speculative.
ental
A s s o c ia t io n b ib l io g r a p h y
1. E w i n g , J a m e s : Neoplastic Disease. Ed. 3. Philadelphia: W. B. Saunders Co., pp. 635-
666 . 2. G l a s s , M ., and R o s e n t h a l , A. H .: Study of Dermoid Cysts with Suggestion as to Use of X -ray in Diagnosis. Am.. J. Obst. & Gynec., 33:813-820, M a y 1937. 3. E w e l l , G. H. : Dermoid Cyst of Ovary Perforating into Urinary Bladder with Pro fuse Hematuria. Am. ]. Surg., 19:502-504, M arch 1933. 4. W o o d , F. C .: Tum ors; in Nelson’ s Loose Leaf Surgery. Vol. 11. N ew York: Thomas Nelson & Sons, 1937, pp. 116 -119 . 2201 Jefferson Avenue East.
SECONDARY DENTIN FORMATION IN THE DECIDUOUS TEETH By
R a lp h
L.
I r e la n d ,
B.S., D.D.S., Lincoln, Nebr.
T has been a matter of conjecture as to whether the deciduous teeth pos sess the ability to form secondary dentin in response to various external stimuli. Noyes, Schour and Noyes say, “The formation of secondary dentin in response to abrasion or caries, the ease with which the deciduous teeth abrade, and their high incidence of caries, pre sent problems necessitating further re search.” 1 Churchill, in his book “Human Odon tography and Histology” says, “The pulp tissue of the deciduous teeth does not, as a rule, react with the formation of adventitious dentin to external stimuli. Persisting elements may constitute an ex ception.” 2 Adventitious dentin is the
I
From the Department of Children’s D en tistry, University of Nebraska, College of Dentistry. Read before the Section on Children’s D en tistry and Oral Hygiene at the Eighty-Second Annual M eeting of the American Dental Asso ciation, Cleveland, Ohio, September 10, 1940.
Jo u r . A .D .A ., V o l. 28 , O cto ber 1941
term used by Churchill instead of sec ondary dentin. Bunting and Hill say, “Deciduous teeth also seem to be almost wholly lacking in the ability to form secondary dentin in response to injury. In them, it would appear that the physiologic tendency is toward resorption of dentin under stimu lation rather than the building of new structures.” 3 In the permanent teeth, secondary den tin is formed in response to various stimuli, such as caries, abrasion, opera tive procedures and chemical and thermal irritation. When the irritation is excessive, secondary dentin is formed much more rapidly and is more irregular in structure. If the irritation is mild, secondary dentin is deposited more slowly and its structure more closely re sembles that of primary dentin. In sound permanent teeth, secondary dentin is also formed intermittently throughout the life of the teeth. The theory is also