ODONTOCELE

From Big Medical Encyclopedia

ODONTOCELE (grech, kystis a bubble) — band education in jaws, an origin to-rogo is connected with pathology of teeth.

In a wedge. to practice distinguish generally two look 3. to.: radicular (root) and follicular (okolokoronkovy). Radicular cysts meet more often; by data A. I. Evdokimova (1964), 3. to. in an upper jaw meets by 3 times more often than in lower.

Etiology and pathogeny

Radicular 3. to. is a cyst of an inflammatory origin, develops from a tooth granuloma (see. Periodontitis ). Destructive process in a granuloma leads to emergence of small cavities (a so-called kistogranulem) which, merging, form one cystous cavity covered by an epithelium.

Follicular 3. to. develops around a crown of not cut through tooth owing to a malformation, noninflammatory cystous transformation of an epithelium of a dental germ (follicle) in an initial phase of formation of enamel. Among the cysts which are a consequence of a malformation of a zuboobrazovatelny epithelium except follicular, distinguish zubosoderzhashchy, primary (primordialny, or to a keratokist), paradental and a cyst of eruption.

Zubosoderzhashchy cyst results from manifestation of eliminativny properties of a dontogenous epithelium of a rudiment of tooth owing to hron, inflammatory process, usually outgoing from milk teeth; the crown of not cut through second tooth is completely created. Primary cyst develops as a result of cystous transformation of a dontogenous epithelium prior to the beginning of a histogenesis of solid tooth fabrics (see. Teeth ). Usually communication of primary cyst with tooth does not manage to be found. Development of a cyst of eruption, as well as a paradental cyst can be probably caused by cystous transformation of a dontogenous epithelium in the course of eruption or hron, an inflammation; at the same time the cystous cover is soldered to a crown of the cutting-through tooth.

Pathological anatomy

3. to. has a cover, in a cut distinguish a periblast from dense fibrous connecting fabric and internal — from a multilayer flat epithelium; contents of a cyst — serous liquid with availability of cholesterol. In a cover of a radicular cyst variously expressed signs hron, inflammations are always observed. In the cyst formed in an upper jaw near a genyantrum, the inner layer of a cover can consist from cylindrical, and sometimes and a ciliary epithelium.

Fig. 1. Diagrammatic representation of frontal section of bones of a facial skull (back view): the okolokornevy cyst (1) squeezes the right genyantrum which lower bound (2) is sharply displaced up; at the left — a genyantrum without changes.

The question of an origin of an epithelium in a cover of a radicular cyst long time was disputable. L. Ch. Malassez in 1885 expressed opinion that the epithelial vystilka of these cysts arises owing to growth of the epithelial remains of a zuboobrazovatelny plate (L. Ch. Malassez's islands) which constantly are found in a periodontium. This assumption received confirmation in N. A. Astakhov (1908), V. R. Braytsev (1907), Remer's researches (O. of Romer, 1900), etc. In 1958 I. Stetsula experimentally confirmed existence of the epithelial remains and proved a possibility of proliferation of their cellular elements with formation of cystous cavities. Growth 3. to., according to one authors, occurs due to growth of an epithelium, at the same time the surrounding bone tissue resolves and reconstructed. Other authors explain growth of a cyst with increase in intracavitary pressure due to accumulation of its contents. By data I. I. Yermolaeva (1972), pressure in a cyst can hesitate from 30 to 95 cm of a water column. On an upper jaw growing 3. to. can displace a maxillary (Highmore's) bosom, leaving from it a narrow crack (fig. 1). Sometimes the bone tissue dividing them completely resolves, and the cover of a cyst adjoins to a mucous membrane of a genyantrum. 3. to. can burgeon also in a nasal cavity.

Clinical picture

3. to. long time asymptomatically proceeds, increase it happens slowly, within several years it can reach to dia. 3 — 4 cm. At the considerable sizes the cyst thins a bone wall that is shown by protrusion of a bone, is more often from a threshold of an oral cavity. At sharp thinning of a bone wall palpatorno over a cyst the characteristic crunch (Dyupyuitren's symptom) is defined, at a full rassasyvaniye of a bone fluctuation is felt. Germination of a cyst in a genyantrum and in a nasal cavity also long time remains imperceptible. The mucous membrane covering the site of a bone according to an arrangement of a cyst usually remains without changes. In the presence of radicular 3. to. the destroyed «causal» tooth affected with caries is defined if it was not removed earlier. The follicular cyst, as a rule, is located on that site of a jaw where the delay of eruption of a second tooth is observed.

3. to. can abscess, usually inflammatory process develops in a radicular cyst and proceeds on type periostitis (see). In cases of an inflammation 3. to. fistula through which pus is emitted can be formed.

The diagnosis

the Diagnosis in most cases, especially in an initial stage, is put by data rentgenol, researches. When 3. to. reaches the big size, limited elastic or crepitant protrusion clinically is found; pain in most cases for a row of years is absent. Diagnostic difficulties can arise in case of a combination 3. to. with hron, antritis (see). Follicular 3. to. it is necessary to differentiate generally with adamantinoma (see). The final diagnosis can be established on a basis a wedge., rentgenol, and gistol, data.

Fig. 2. The intra oral roentgenogram of teeth of an upper jaw with a radicular cyst of the central and side cutters (it is specified by an arrow).
Fig. 3. The intra oral roentgenogram of teeth of an upper jaw with an okolokoronkovy follicular cyst of the impacted canine (it is specified by an arrow).

At X-ray inspection do the intra oral roentgenogram; at very big cyst it is necessary to resort to the extraoral roentgenogram. The most important symptom of a cyst in the x-ray image is the rounded or oval shape of defect of a bone with the smooth and accurately outlined contours, and also a thin strip of the condensed bone tissue around a cavity. The radicular cyst is connected with a top of a root (fig. 2) which can freely stand in a cavity of a cyst. In a gleam of a follicular cyst a coronal part (fig. 3) quite or partially created tooth or several underdeveloped teeth among which often one is quite created is always projected. Rentgenol, a picture of a follicular cyst is usually characteristic, extremely seldom multitooth follicular cyst according to the shadow image can remind so-called cystous odontoma (see). At the suppurated cyst or acute inflammatory process in a surrounding bone tissue contours of a cyst on the roentgenogram are greased, can change and a form of a cyst, in its circle signs of destruction of a bone tissue appear. At a large radicular cyst on the roentgenogram the shift of roots of the next teeth is visible. With a growth of a cyst in an upper jaw the pushing off of a bottom of a genyantrum sometimes is visible; in a mandible at destruction of spongy substance and thinning of a compact layer radiological patol, the change sometimes is found.

At the cyst which got into a genyantrum, exhaustive data manage to be obtained by means of contrast gaymorografiya (see). At administration of contrast medium in a genyantrum the cyst on the roentgenogram is found in the form of rounded shape of defect of filling against the background of a homogeneous intensive shadow of the contrast agent filling a bosom.

Treatment

Treatment operational. Only at small (to 8 mm to dia.) to a radicular cyst (kistogranulema) its treatment by sealing of the channel of tooth of cementomas is sometimes possible (see. Sealing of teeth ) with obligatory removal of cement for an apical opening in a cavity of a cyst.

Operations consist or in full removal of a cyst with its cover (cystectomy), or in partial excision of a cover of a cyst and formation of the message with an oral cavity (Vesicotomy). The cystectomy is shown at the cysts which are a malformation of a dontogenous epithelium. Vesicotomy can be recommended only at the cysts having an inflammatory origin (radicular) or as a temporary action at a follicular cyst of the big size when full enucleation of a cyst is accompanied by danger of injury of the next cavities (a genyantrum, the nasal courses) or exposures and damages of a neurovascular bunch on a mandible. As a rule, on an upper jaw operation is performed under an infiltration anesthesia, and on a mandible — under conduction. At operation in the field of cutters and canines on a mandible the infiltration anesthesia can be carried out (see. Anesthesia local ). Before operation by means of an electric pulp test it is necessary to define vitality of a pulp of the teeth adjoining to 3. to. If carrying out a cystectomy, then the teeth located in borders 3 is supposed. to., the cysts which are projected on the roentgenogram against the background of contours, it is necessary to depulpirovat and seal up their channels of cementomas.

Fig. 4. Diagrammatic representation of some stages of a cystectomy: and — the line of the arc-shaped section (black color) in the field of an arrangement of a cyst; — a mucous and periosteal rag otsloyen; in — the bone wall is removed, flaking of a cover of a cyst; — the cyst is removed, the top of a root is resected; the slizistonadkostnichny rag is sewn; 1 — a mucous and periosteal rag, 2 — a bone wall, 3 — a cover of a cyst, 4 — a top of a root, 5 — the sealed-up pulp cavity.

A cystectomy

Quick access usually from an oral cavity (fig. 4). Find a semi-lunar or trapezoid mucous and periosteal rag in the field of an arrangement of a cyst, the basis to-rogo shall be turned to a body of a jaw. The mucous and periosteal rag is otslaivat, the naked bone is trepanned a spear-point drill, a cylinder-shaped cutter or a chisel, then expand an entrance to a cyst with bone nippers. The cover of a cyst is otslaivat the curved raspatory. The fangs turned into a cavity of a cyst are subject to a resection. The bone cavity is washed out hydrogen peroxide, solution of an antiseptic agent. Sometimes apply sealing of a bone cavity an absorbable gelatin sponge, spongy substance of a tinned gomokost that, according to some authors, accelerates process of an osteogenesis. The mucous and periosteal rag is fixed several seams from a thin suture material. Apply a compressing bandage for 2 — 3 hours for the purpose of the prevention of a hematoma a lip or a cheek. Seams remove on 5 — the 6th day after operation.

At correctly performed operation the cavity of a cyst is filled with a blood clot which is exposed to process of the organization, and in 3 — 5 months there comes complete regeneration of a bone tissue.

Fig. 5. Diagrammatic representation of some stages of vesicotomy: and — the mucous and periosteal rag otsloyen is also raised, the bone wall is removed; — the top of a root is resected, the slizistonadkostnichny rag is screwed in a cavity of a cyst, the cavity of a cyst is plugged; 1 — a mucous and periosteal rag, 2 — a top of a root, 3 — the sealed-up pulp cavity, 4 — a tampon in a cavity of a cyst.

Vesicotomy

Hod of an operative measure until an exposure of a cover of a cyst is same, as well as at a cystectomy. If the resection of roots is supposed, the mucous and periosteal rag is found the basis to edge of an alveolar shoot. After trepanation delete a bone wall and contents of a cyst and excise the forefront of its cover. Then carry out a resection of tops of fangs, vystoyashchy to a cavity of a cyst, and tampon the formed bone cavity a yodoformny gauze (fig. 5). In 5 — 7 days the tampon is changed; further it is necessary to tampon only an entrance to a cavity. Packing of a cavity is stopped in 3 — 4 weeks, then the patient daily washes out weak solution of potassium permanganate or hydrogen peroxide a postoperative cavity, using a rubber bulb with a soft tip. Depth of a cavity gradually decreases; 6 — 8 months later only insignificant bone deepening covered with a normal mucous membrane is found in most of patients on its place.

If 3. to. considerably pushes aside a genyantrum, but does not perforate it, it is more reasonable to carry out vesicotomy. Especially it is shown at persons of young age since in 6 — 12 months on site of a cyst there is a small bone deepening, and the genyantrum accepts the normal size again. At elderly people in view of decrease in recovery processes it is more reasonable to connect 3. to. with a genyantrum with formation of an anastomosis in the closing nasal stroke, as at operation for antritis (see. Antritis ); the wound from an oral cavity is sewn up tightly. The integrated cavity exists further as a genyantrum.

Forecast at the correct treatment favorable.

Prevention comes down to timely treatment of the second and milk teeth affected with carious process.



Bibliography: Vernadsky Yu. I. Fundamentals of surgical stomatology, page 311, etc., Kiev, 1970; Evdokimova. And. ivasilyevg. A. Surgical stomatology, page 244, M., 1964; Zedgenidze G. A. and Shilova-Mekhanik R. S. Radiodiagnosis of diseases of teeth and jaws, page 183, M., 1962, bibliogr.; Rabukhina N. A. Radiodiagnosis of some diseases of dentoalveolar system, M., 1974; The Guide to surgical stomatology, under the editorship of A. I. Evdokimov, page 359, M., 1972.

P. V. Naumov; G. A. Zedgenidze (rents.).

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