Radicular Cysts of the Maxilla and Mandible.

Three Cyst Cases

The History of These Patients is Discussed by

Dr. Thomas O. Robinson in

‘RADICULAR CYSTS OF THE MAXILLA AND MANDIBLE”

 

                While there is much diversion of opinion among authorities regarding the formation of cysts of dental origin, the theory has been held for some time that these cysts develop from irritation—or stimulation. The irritating about the apex of a tooth as a result of infection following the death of the dental pulp.

Radicular cysts, sometimes called dentoperiosteal, or root cysts, are the most common form found about the jaws. Some authorities give a ratio of radicular type, to follicular type at 40:1. This may be a high average but we do know that the radicular cysts are found most frequently in young people—especially about the apex of the lateral incisor as it is completely surrounded by cancellous tissue.

Since radicular cysts are the results of chronically infected teeth and form about the inflamed peridental membrane—it is reasonable to believe that a migration, or proliferation of epithelial cell-rests which form the lining of the cyst wall attach themselves to the peridental membrane and later, or under a traumatic or chemical irritation, begin to secrete a serous fluid which fills up the cyst wall.

The wall of a fully developed cyst consists of a dense fibrous capsule lined with several layers of squamous, or cuboidal epithelial cells. The cystic fluid is alkaline, of a viscid consistency identified by a yellowish straw color. It contains a fat-like pearly substance known as cholesterin crystals. The fluid is usually sterile both by smear and culture; however, infection of the cyst wall frequently converts it into pus.

Radicular cysts vary in size from the diameter of a small pea to the extent in which they occupy the greater part of the maxilla and mandible. In the maxilla they may push up the floor of the maxillary sinus or the nasal fossa, but rarely actually open these cavities. By extension, a cyst may gradually involve the roots of adjacent teeth, causing secondary pulp devitalization, and in the maxilla stimulate an empyema of the antrum.

 

Cysts have a tendency through pressure to cause resorption of bone tissue. Usually the external plate is involved assuming a paper-like thinness and upon digital manipulation the characteristic celluloid crackling sound may be heard.

The pressure of the cystic fluid is generally in one direction, thereby destroying only one plate of bone; however, examination of the roentgenogram of an extensive cyst gives the appearance that both plates are involved, offering the possibility of a pathologic fracture, or the possibility of a fracture since the main body of the bone appears destroyed. Large cysts in edentulous areas in the maxillary dental ridge require meticulous radiographic interpretation concerning their relation to the antrum and to the nasal floor.

Report of Cases

I wish to present three cases of “Radicular Cysts” from my service as Chief of the Dental Staff in Samuel Merritt Hospital:

Case I

                A.N., a student, male, age 10, presented a history of having been struck in the lower anterior teeth by a tennis racket. This happened two years prior to the time complications arose. He complained to his mother of a pimple on his chin and she proceeded to open it with a darning needle. This incident was followed by swelling and pain in the lower anterior region of the mandible. Upon examination by their physician—conclusions were made that the area had become infected.

The gum tissue was lanced to eliminate pus, but the swelling and pain still continued. The patient was referred to me for consultation May 9, 1935. Digital examination produced intense pain and pronounced edema was present. Fig I-a. Roentgenograms were ordered and a large cystic area was noted about the region of the symphysis involving the apices of the incisors of the mandible. See Fig. I-B.

                He was admitted to the hospital May 10, 1935, and I operated May 11, 1935, under a general anesthetic. A curved incision was made and the mucoperiosteal flap was retracted to expose the cystic area. The labial wall had a definite bulge and was easily removed.

A complete enucleation was performed. Bleeding was stimulated and the flap sutured down with a curved notch cut in the center of the flap (Cogswell Method) in which Vaseline gauze was loosely packed for drainage. A smear was taken and the laboratory findings were negative. A report of the culture was returned as non-haemolytic streptococcis.

Joe packs were applied and the area painted at four hour intervals with viogen. The gauze was renowned 24 hours later and the wound irrigated daily with a warm saline solution. Rapid recovery followed and the patient was dismissed from the hospital five days following the operation.

                A radiographic checkup was made August 31, 1935, and definite granulation of the cyst cavity was noted. Fig. II. The apex of the right central incisor, this being the injured tooth since it had a fractured incisal edge, showed a small granuloma. The tooth was movable with no “pain response” on percussion. I decided to extract the tooth Jan. 3, 1936, and curetted the area. Fig. III. The socket healed uneventfully. The final X-ray showed new deposition of calcified bone tissue in the area involved. Fig. IV.

Conclusions

  1. Undetected case of radicular cyst, disclosed by mother’s interference with a skin eruption.
  2. Lancing of gum tissue by physician brought no permanent relief.
  3. Surgical interference removed edema and pain, except apical infection.
  4. Rapid recovery followed and new bone growth soon developed after removal of injured incisor.

Case II

J.F.W., male, age 35, was admitted to the hospital October 2, 1935. Had been examined by a local dentist with hospitalization recommended.

Symptoms and signs on admission after examination by three staff physicians were:

  1. Acute pain in left upper and lower jaws.
  2. Pain, drooping, dizziness and many dental caries were noted.
  3. Referred to dental staff and complete roentgenograms were ordered of jaws and mouth.
  4. Report of department of Roentgenology was as follows: “There is a cyst about 3 cc. in diameter in left mandible, below in front of first molar. Large infectious granuloma around roots of molar teeth. Infection of roots of several teeth.”
  5. Diagnosis:—Radicular cyst, and abscessed teeth, surgery recommended.

My digital examination disclosed a large well rounded, hard swelling on the external plate of the mandible. Palpation and pressure extra-orally produced no definite pain or fluctuation, but a slight crepitation was noted when pressure was exerted on the facial surface. There was also a perceptible movement of the lower left first molar. Fig. I.

Oct. 4, 1935, the patient was prepared for surgery. Morphine sulphate 1/6 gr. With atropine 1/150 gr. were administered previous to the operation. Gas induction with ether was used for the anesthetic.

The infected teeth were removed, Fig. II, sockets curetted and bone tissue trimmed and sutured.

                The lower left first molar was extracted and a curved incision was made from the buccal of the second molar to apical region of first bicuspid. The mucoperiosteum was elevated and a thin plate of bone was found externally over the first molar region. This was removed and a complete enucleation was performed. The usual suturing of the mucoperiosteal flap was made and a small opening trimmed to insert a gauze drain to permit irrigation.

Conclusions

  1. Exploration and examination of cyst wall and cavity confirmed that the pressure of the cystic fluid is usually in only one direction.
  2. In this case the external plate and cortical ray of bone were practically destroyed, while the internal plate remained intact—thus maintaining the integrity of the bone.
  3. Clinical symptoms and signs disappeared following operation of cyst and extraction of infected teeth.
  4. The patient returned to his occupation, and gained ten pounds in weight during the four months following the operation.

Case III

The following case of “Radicular Cyst,” as reported in the Journal A.D.A., Vol. 23, Jan., 1936, was of special interest because of the unusual look of the growth, the simple technic of its removal and the complete disappearance of symptoms after the operation:

E.K., a student, male, aged 20, had a painful swelling of the right side of the face and neck with constant headache and drowsiness. On rotation of his head to the left, the tension increased the pain, which was dull during the day but invariably became worse at night. This pain also involved the right shoulder.

The patient described a sensation of constant pressure in the roof of the mouth and right side of the face. He also complained of a “feeling of water” in the right ear, and blurred vision in the right eye, with lachrymation. At age 13, several teeth were filled, pain the upper right lateral incisor following shortly. Six months before the patient was referred to me, he was examined in the clinic where dentigerous cyst was diagnosed and removal advised. No surgical work was done. The patient was referred to the dental staff of Samuel Merritt Hospital, where he was seen by me October 22, 1934.

                The face showed great swelling (Fig. I) and complete roentgenograms were made. Stereoscopic views of the head showed a clearly defined cystic area originating at the apex of the right maxillary lateral incisor, extending backward to the malar region of the upper second molar, encroaching on the maxillary sinus, pushing the floor upward and backward and extending forward and upward to the nasal fossa. Fig. II. Much edema was present in the palatal area and the egg-shaped mass was, upon digital examination, found to be quite movable but with no crepitus, buccal or lingual.

                Upon roentgenographic examination I decided to extract the upper right lateral incisor under a local anesthetic. 3 cc. of serous, straw colored fluid from the cyst cavity was obtained. This with a smear from the root of the tooth was given to the bacteriologist, who reported “mixed flora.” Mostly streptococci, with a few staphylococci and diphterioids present.

Since there had been definite chronic inflammation about the apex of the lateral incisor resulting from infection following the death of the dental pulp, it was concluded the growth was a radicular cyst. Fig. III. There was no tooth or enamel capsule present in the cyst cavity as found in the follicular or dentigerous cyst, therefore this ruled out the former diagnosis of dentigerous cyst.

                Surgical interference with a general anesthetic was decided the proper method of approach. Gas induction with ether was administered. A curved incision was made beginning at the right second molar to 5 mm. to the left of the frenum anteriorly. The mucoperiosteal flap was turned up to expose the labial bony plate of the cyst. A complete enucleation was performed by removing the outer wall sufficiently so that the cyst sac was shelled out in its entirely by blunt dissection. It was found unnecessary to extract any of the remaining teeth and the cavity was loosely packed with Vaseline gauze and a drain inserted. The flap was sutured down to place with a curved opening being made for the drain and subsequent irrigation. A section of the cyst was sent to the laboratory and the following report returned:

“Benign radicular cyst showing acute and chronic inflammatory reaction.”

The patient made a satisfactory recovery and the gauze pack was removed within forty-eight hours, with daily irrigation for two weeks. Fifteen days after the operation the patient was dismissed from the hospital as all former symptoms had disappeared. Fig. IV.

                Regular office calls followed for several weeks at which time electric pulp tests were made of the remaining teeth involved in the cyst area. Poor vitality response was registered at first; however, the vitality has been observed to be steadily improving. Radiographs have been taken at regular six month intervals and now, at a period of one year and six months, definite areas of calcified bone tissue can easily be discerned. Fig. V.

Conclusions

  1. This was an unusually large cyst measuring 70 mm. in length and 43 mm. in width and 15 mm. at the apex.
  2. Only a minimum amount of bone tissue was destroyed in the removal of the cyst.
  3. The left lateral incisor was removed. The remaining teeth left intact.
  4. Original symptoms have disappeared and the patient has made a complete and satisfactory recovery.

The above cases are not adduced because of their rarity. On the contrary any dentist may encounter such in the course of his daily practice. Your attention will be called to the fact that these cases were all operated by complete enucleation. In my experience better results are obtained by this method; thus the early deposition of new calcified bone and the maintaining of the original contour of the cyst wall. The Partsch method results in a slow decrease in size and depth of the bone cavity with a shallow depression following. The important points in relation to radicular cysts are:

  1. Early recognition.
  2. Radical surgery.
  3. Adequate drainage and post-operative precautions.

Thomas O. Robinson D.D.M.

207 Acheson Physicians Bldg.,

Berkeley, California.

 

 

BIBLIOGRAPHY

  1. Endelman, Julio and Wagner, A.F. General and Dental Pathology. 1920.
  2. Blair, V.P., and Ivy, Robert H. Essentials of Oral Surgery. 1922.
  3. Harris, Leon. Common Cysts of the Jaws.
  4. Mead, Sterling V. Diseases of the Mouth. 1933.
  5. Mead, Sterling V. Oral Surgery. 1934.
  6. Cogswell, Wilton W. Dental Oral Surgery. 1932.
  7. Paine, W.S. Review of Principles Involved in Exodentia. 1929.
  8. Robinson, Thos. O. Jour. A.D.A. Vol. 23, Jan, 1936.

 

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