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Infected globulomaxillary cyst
INFECTED
GLOBULOMAXILLARY
CYST
Report of a Case JAYME FILGUEIRAS, CID., AND SYLVIO BEVILACQUA, C.D.,* RIO DE JASEIRO, BRAZIL URING the early life of the human embryo, the future mouth region is the site of quite complex changes which, by the end of the second month, terminate by the fusion of several processes to form the facial part of the head. Developmental anomalies in the anterior maxillary region are not infrcquent. Aside from malformations known as clefts, resulting from a total or partial failure of union between different processes, the attention of investigators has been focused on cysts which may arise from epithelial remnants in the line of closure. Studies by Meyer,l Stafne and Austin,” 5urket,3 and Thorna showed that those cysts are of not uncommon occurrence. As a matter of fact, as Sicher5 pointed out, we may find dermoid or epidermoid cyst,s at any fusion point in the body. The cysts located in the anterior maxillary region, with the exception of radicular cysts, belong to the following categories : nasoalveolar, median palatal, globulomaxillary, and incisive canal cysts. According to Robinson,‘j they are classified as developmental cysts arising from nondental tissues. The epithelium that serves as the nidus for the formation of these cysts is derived from embryonic epithelial inclusions. There is not yet a satisfwctory explanation for the initiation of cyst formation, and the lesions stand ai a dubious position between the inflammatory hyperplasias and the neoplast,it* processes. The globulomaxillary cyst, such as the one reported here, like the other, developmental or fissural cysts, is relatively rare. It, develops from residual epithelium along the line of fusion between the nasomedial (globular) nnrl maxillary processes. Unless complicated by an acute episode, these cysts are symptomless, being found on routine dental x-ray examination, An earl? indication of their presence may be a change in position of the lateral incisor and canine forced apart by the growing cyst. Later, expansion of the cortex may occur with bulging in the alveolar plate usually at the labial surface of tl1r1 maxilla. Often the microscopic picture does not differ from a radicular cyst, aithough Robinson, Koch, and Jasper? have found ciliated columnar epithelium. The final diagnosis is made on the basis of clinical data.
D
*Assistant professor, Department l’niversity of Brazil, Rio de Janeiro.
of Pathology
an<1
Thempvutics.
School of
Dentists
y.
506
JAYME
PILGUEIRAS
ANI)
SYLVIO
BEWLACQUA
Case Report M. V. C., a 13-year-old girl, in the beginning of August, 1954, complained of a l):td taste and a few days later felt a very severe pain in the left maxillary region. Her temperature was high (slightly above 102.2” F.). A small swelling had formed on the anterior part of the hard palate near the cervical border of the canine. At first, there was a discharge of pus through the gingival crevice between the lateral incisor and canine, followed by a yellowish fluid. The acute symptoms subsided with the establishment of penicillin therap? (400,000 units every twelve hours).
Fig. l.- +4 and B, Large monocystic and canine forcing apart the roots of these
tion.
Note bone regeneration
in progress.
area of rarefaction
teeth.
C, Radiograph
between taken
the left lateral incisor months after opera-
five
The Dental Examination.-When first seen, the patient was quite comfortable. clinical examination was essentially negative. The soft tissues were normal in color and the teeth gave a normal response to the several diagnostic tests (thermal and electric). Palpation failed to reveal any fluctuation or “crackling” sensation. Roentgenographic examination showed a pear-shaped radiolucent area extending from the alveolar crest between the left lateral incisor and canine up into the maxilla (Fig. 1, d and B). The roots of the teeth were pushed apart b?- the pressure of what seemed to be an expanding growth. The definite boundary of dense, sclerotic bone which usually surrounds the cyst membrane was absent. The location, the vitality of the adjacent teeth, and the acute episode led to a preoperative diagnosis of an infected globulomaxillary cyst.
INFECTED
GLoBu~,OM.~~I~,L.~~~
3li
WsT
A.
B.
c.
B, Higher-power x%?w ui cyst wall showin:: Low-pou cr view of cyst “sac.” Fig. 2.--A, There is no inflammatory exudate in the epithelial lining composed of several layers of cel!s. G, Higher-power view of arer! the underlying connective tissue, and the epithelium IS intact. IIf cyst and ~Jseu~loe~~ltllelioniI<>xtreme inflammatory reaction ?vlthir,I the ~a11 marked in A. atous hyperplasia of stratifled sqU&moUs ePithellUn1 IlmW.
508
JAYME FILGUEIRAS AND SYLVIO BEVILACQUA
Operation.-After laboratory studies (bleeding and coagulation time, tourniquet test, and urinalysis), the patient was medicated with penicillin (400,000 units) and Botropase (snake venom, 1 cc.) intramuscularly one hour before operation. Under block anesthesia, a mucoperiosteal flap was reflected. With a No. 3 bur, four holes were drilled through the cortical plate of bone overlying the pathologic area. The holes were connected and the bone was removed with a spatula exposing the cyst which, at that time, drained some pus. The opening was enlarged with rongeur forceps to make enucleation easier. The crypt was irrigated with saline solution and smoothed, and the flap was sutured into place. Postoperative Course.-An ice bag was applied for the first twenty-four hours, and careful mouth hygiene was recommended (saline mouthwash). Penicillin every twelve hours (400,000 units) for four days was prescribed. On the day after operation there was marked edema without pain. In the subsequent days the edema was somewhat less. By the fifth postoperative day the sutures were removed, and after eight days the patient was discharged. A radiograph taken five months after the operation showed healing in progress (Fig.
1, C).
Pathologic Examination.-The specimen consisted of a piece of soft tissue measuring 2 by 0.5 cm. Microscopic examination showed a cyst wall lined with stratified squamous epithelium varying in thickness but, for the most part, quite t,hick. In some areas the epithelium was intact and sharply demarcated from the underlying connective tissue (Fig. 2, B); in other areas it showed destruction and pseudoepitheliomatous hyperplasia due to inflammatory reaction (Fig. 2, a and C). In these areas the connective tissue was heavily infiltrated by lymphocytes, plasma cells, and polymorphonuclear leukocytes, and presented newly formed capillaries. Diagnosis,-Globulomaxillary
cyst with signs of acute inflammatory
reaction.
References Meyer,
A. W.:
Median Anterior
Maxillary
;: Stafne, Edward C., and Austin, Louie T.:
Cysts, J. Am. Dent. A. 18: X351-1877, 1931. Median Anterior Maxillary Cysts, J. Am.
Dent, A. 23: 801-809, 1936. 3. Burket, Lester W.: Nasopalatine Duct Structures and Peculiar Bony Pattern Observed in Anterior Maxillary Region, Arch. Path. 23: 793-800, 1937. Thoma, K. H.: Facial Cleft and Fissural Cysts, Int. J. Orthodontia 23: 83, 1937. 2 Sicher, Harry, in Orban, B.: Oral Histology and Embriology, ed. 3, St, Louis, 1953, The C. V. Mosby Company, p. 28. 6. Robinson, H. B. G.: Classification of Cysts of the Jews, Am. J. Orthodontics and Oral Burg. 31: 370-375, 1945. Cyst, Am. 7. Robinson, H. B. cf., Koch, W. E., and Jasper, L. N.: Infected Globulomaxillary J. Orthodontics and Oral Surg. 29: 608,1943. Av. PASTEUR,438.
GLOBULOMAXILLARY
CYST
Report of a Case JAYME FILGUEIRAS, CID., AND SYLVIO BEVILACQUA, C.D.,* RIO DE JASEIRO, BRAZIL URING the early life of the human embryo, the future mouth region is the site of quite complex changes which, by the end of the second month, terminate by the fusion of several processes to form the facial part of the head. Developmental anomalies in the anterior maxillary region are not infrcquent. Aside from malformations known as clefts, resulting from a total or partial failure of union between different processes, the attention of investigators has been focused on cysts which may arise from epithelial remnants in the line of closure. Studies by Meyer,l Stafne and Austin,” 5urket,3 and Thorna showed that those cysts are of not uncommon occurrence. As a matter of fact, as Sicher5 pointed out, we may find dermoid or epidermoid cyst,s at any fusion point in the body. The cysts located in the anterior maxillary region, with the exception of radicular cysts, belong to the following categories : nasoalveolar, median palatal, globulomaxillary, and incisive canal cysts. According to Robinson,‘j they are classified as developmental cysts arising from nondental tissues. The epithelium that serves as the nidus for the formation of these cysts is derived from embryonic epithelial inclusions. There is not yet a satisfwctory explanation for the initiation of cyst formation, and the lesions stand ai a dubious position between the inflammatory hyperplasias and the neoplast,it* processes. The globulomaxillary cyst, such as the one reported here, like the other, developmental or fissural cysts, is relatively rare. It, develops from residual epithelium along the line of fusion between the nasomedial (globular) nnrl maxillary processes. Unless complicated by an acute episode, these cysts are symptomless, being found on routine dental x-ray examination, An earl? indication of their presence may be a change in position of the lateral incisor and canine forced apart by the growing cyst. Later, expansion of the cortex may occur with bulging in the alveolar plate usually at the labial surface of tl1r1 maxilla. Often the microscopic picture does not differ from a radicular cyst, aithough Robinson, Koch, and Jasper? have found ciliated columnar epithelium. The final diagnosis is made on the basis of clinical data.
D
*Assistant professor, Department l’niversity of Brazil, Rio de Janeiro.
of Pathology
an<1
Thempvutics.
School of
Dentists
y.
506
JAYME
PILGUEIRAS
ANI)
SYLVIO
BEWLACQUA
Case Report M. V. C., a 13-year-old girl, in the beginning of August, 1954, complained of a l):td taste and a few days later felt a very severe pain in the left maxillary region. Her temperature was high (slightly above 102.2” F.). A small swelling had formed on the anterior part of the hard palate near the cervical border of the canine. At first, there was a discharge of pus through the gingival crevice between the lateral incisor and canine, followed by a yellowish fluid. The acute symptoms subsided with the establishment of penicillin therap? (400,000 units every twelve hours).
Fig. l.- +4 and B, Large monocystic and canine forcing apart the roots of these
tion.
Note bone regeneration
in progress.
area of rarefaction
teeth.
C, Radiograph
between taken
the left lateral incisor months after opera-
five
The Dental Examination.-When first seen, the patient was quite comfortable. clinical examination was essentially negative. The soft tissues were normal in color and the teeth gave a normal response to the several diagnostic tests (thermal and electric). Palpation failed to reveal any fluctuation or “crackling” sensation. Roentgenographic examination showed a pear-shaped radiolucent area extending from the alveolar crest between the left lateral incisor and canine up into the maxilla (Fig. 1, d and B). The roots of the teeth were pushed apart b?- the pressure of what seemed to be an expanding growth. The definite boundary of dense, sclerotic bone which usually surrounds the cyst membrane was absent. The location, the vitality of the adjacent teeth, and the acute episode led to a preoperative diagnosis of an infected globulomaxillary cyst.
INFECTED
GLoBu~,OM.~~I~,L.~~~
3li
WsT
A.
B.
c.
B, Higher-power x%?w ui cyst wall showin:: Low-pou cr view of cyst “sac.” Fig. 2.--A, There is no inflammatory exudate in the epithelial lining composed of several layers of cel!s. G, Higher-power view of arer! the underlying connective tissue, and the epithelium IS intact. IIf cyst and ~Jseu~loe~~ltllelioniI<>xtreme inflammatory reaction ?vlthir,I the ~a11 marked in A. atous hyperplasia of stratifled sqU&moUs ePithellUn1 IlmW.
508
JAYME FILGUEIRAS AND SYLVIO BEVILACQUA
Operation.-After laboratory studies (bleeding and coagulation time, tourniquet test, and urinalysis), the patient was medicated with penicillin (400,000 units) and Botropase (snake venom, 1 cc.) intramuscularly one hour before operation. Under block anesthesia, a mucoperiosteal flap was reflected. With a No. 3 bur, four holes were drilled through the cortical plate of bone overlying the pathologic area. The holes were connected and the bone was removed with a spatula exposing the cyst which, at that time, drained some pus. The opening was enlarged with rongeur forceps to make enucleation easier. The crypt was irrigated with saline solution and smoothed, and the flap was sutured into place. Postoperative Course.-An ice bag was applied for the first twenty-four hours, and careful mouth hygiene was recommended (saline mouthwash). Penicillin every twelve hours (400,000 units) for four days was prescribed. On the day after operation there was marked edema without pain. In the subsequent days the edema was somewhat less. By the fifth postoperative day the sutures were removed, and after eight days the patient was discharged. A radiograph taken five months after the operation showed healing in progress (Fig.
1, C).
Pathologic Examination.-The specimen consisted of a piece of soft tissue measuring 2 by 0.5 cm. Microscopic examination showed a cyst wall lined with stratified squamous epithelium varying in thickness but, for the most part, quite t,hick. In some areas the epithelium was intact and sharply demarcated from the underlying connective tissue (Fig. 2, B); in other areas it showed destruction and pseudoepitheliomatous hyperplasia due to inflammatory reaction (Fig. 2, a and C). In these areas the connective tissue was heavily infiltrated by lymphocytes, plasma cells, and polymorphonuclear leukocytes, and presented newly formed capillaries. Diagnosis,-Globulomaxillary
cyst with signs of acute inflammatory
reaction.
References Meyer,
A. W.:
Median Anterior
Maxillary
;: Stafne, Edward C., and Austin, Louie T.:
Cysts, J. Am. Dent. A. 18: X351-1877, 1931. Median Anterior Maxillary Cysts, J. Am.
Dent, A. 23: 801-809, 1936. 3. Burket, Lester W.: Nasopalatine Duct Structures and Peculiar Bony Pattern Observed in Anterior Maxillary Region, Arch. Path. 23: 793-800, 1937. Thoma, K. H.: Facial Cleft and Fissural Cysts, Int. J. Orthodontia 23: 83, 1937. 2 Sicher, Harry, in Orban, B.: Oral Histology and Embriology, ed. 3, St, Louis, 1953, The C. V. Mosby Company, p. 28. 6. Robinson, H. B. G.: Classification of Cysts of the Jews, Am. J. Orthodontics and Oral Burg. 31: 370-375, 1945. Cyst, Am. 7. Robinson, H. B. cf., Koch, W. E., and Jasper, L. N.: Infected Globulomaxillary J. Orthodontics and Oral Surg. 29: 608,1943. Av. PASTEUR,438.